discharge planning, nursing interventions, nursing classification, Omaha System, patient problems, transitional care



  1. Bowles, Kathryn H. PhD, RN


Standardization and computerization of medical documentation has provided a method to describe patient care by naming and linking patients' needs with nursing interventions. This study used a standardized nursing classification system to describe the types and frequency of problems experienced by elders hospitalized and discharged to home and the interventions used by staff nurses and advanced practice nurses (APNs) as they provided acute care and discharge planning for these cardiac patients. The patients' hospital records and the APN logs were content analyzed and then coded using the Problem Classification Scheme and Intervention Scheme of the Omaha System. Patients experienced an average of 8.6 problems that required a total of 7,000 interventions in all four Omaha System intervention categories. The results provided a description of the most frequent problems experienced by the patients linked with the most common nursing interventions. The nature, complexity, and prevalence of patient problems and the importance of communication across settings are evident. In addition, the study findings increase understanding of the contribution of nurses to the care of hospitalized elders as they make the transition from hospital to home.