Keywords

Clinical Care Classification System, Clinical decision support, Clinical judgment, Nursing diagnosis

 

Authors

  1. Yang, Lei BS, RN, APN, ICU CNS, HEMS CNS
  2. Xu, YanDuo BS, RN, ICU CNS
  3. Ji, XiaoBo BS, RN, ICU CNS
  4. Wang, Zhuan BS, RN, ICU CNS
  5. Cao, Chuan BS, RN, ICU CNS
  6. Chong, PeiLong PhD
  7. Wu, ZhiJun MPH

Abstract

Few nursing informatics studies focus on selecting nursing diagnoses for critical patients. The absence of data about nursing clinical judgment in the care of patients with cerebral hemorrhage greatly hinders research progress in evidence-based care. A stratified, retrospective study analyzed 115 electronic "intelligent" nursing information system nurse assessments and nursing diagnoses. Data were documented from April 2019 to November 2020 for critically ill patients admitted with cerebral hemorrhage in a 10-bed medical ICU at a 1500-bed tertiary facility, Henan Honliv Hospital, in Henan Province, China. In the selection of nursing diagnoses among nurses of stratified competencies (novice to expert), novice and experienced nurses were found to have significant variances in selecting nursing diagnoses for critically ill patients with cerebral hemorrhage. Novice nurses more frequently selected the Activity Intolerance Risk diagnosis as an initial diagnosis (P = .025). Experienced nurses selected the Fluid Volume Excess Risk diagnosis more frequently (P = .003). Consequently, nursing information systems are important in evaluating professional practice. The access to structured, standardized nursing data for the complete nursing process enables nurse managers to comprehensively analyze the nursing care given to patients, the distribution of patient nursing diagnoses, and the status of patient care risks.