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Biomedical subjects

Anna Ehrenberg

Publications and source records attributed to Anna Ehrenberg.

24 records · Page 2Linked to original sources
PubMedDate not supplied

Accuracy and quality in the nursing documentation of pressure ulcers: a comparison of record content and patient examination.

OBJECTIVE: To determine the accuracy and describe the quality of nursing documentation of pressure ulcers in a hospital care setting. DESIGN: A cross-sectional survey was used comparing retrospective audits of nursing documentation of pressure ulcers to previous physical examinations of patients. SETTING AND SUBJECTS: All inpatient records (n = 413) from February 5, 2002, at the surgical/orthopedic (n = 144), medical (n = 182), and geriatric (n = 87) departments of one Swedish University hospital. INSTRUMENTS: The European Pressure Ulcer Advisory Panel data collection form and the Comprehensiveness In Nursing Documentation. METHODS: All 413 records were reviewed for presence of notes on pressure ulcers; the findings were compared with the previous examination of patients' skin condition. Records with notes on pressure ulcers (n = 59) were audited using the European Pressure Ulcer Advisory Panel and Comprehensiveness In Nursing Documentation instruments. RESULTS: The overall prevalence of pressure ulcers obtained by audit of patient records was 14.3% compared to 33.3% when the patients' skin was examined. The lack of accuracy was most evident in the documentation of grade 1 pressure ulcers. The quality of the nursing documentation of pressure ulcer (n = 59) was generally poor. CONCLUSIONS: Patient records did not present valid and reliable data about pressure ulcers. There is a need for guidelines to support the care planning process and facilitate the use of research-based knowledge in clinical practice. More attention must be focused on the quality of clinical data to make proper use of electronic patient records in the future.

Adolescent↗
PubMedDate not supplied

Fatigued elderly patients with chronic heart failure: do patient reports and nurse recordings correspond?

PURPOSE: To compare descriptions of fatigue from interviews with elderly people with chronic congestive heart failure (CHF) and data recorded by nurses at an outpatient heart failure clinic. METHODS: Patients (N = 158) were screened for moderate to severe CHF and interviewed using a revised form of the Fatigue Interview Schedule (FIS). Seventy-nine of these patients were offered visits at a nurse-monitored heart failure clinic. Nursing documentation of fatigue in patient records (n = 56) at the heart failure clinic was compared to the patient interviews. FINDINGS: Results indicated poor concordance between patients' descriptions and record content concerning fatigue. Decreased libido was linked to fatigue according to the patients but not to the nurses' notes. Cognitive characteristics of fatigue were rarely recorded, but were more frequent in patient interviews. CONCLUSIONS: Nurses must recognize characteristics and factors related to fatigue in patients and develop strategies to help patients cope with their restricted ability in daily life. PRACTICE IMPLICATIONS: Using the words and expressions of the patients and the diagnostic characteristics of fatigue in record-keeping can support the nurses understanding of patients living with CHF.

Aged↗
PubMedDate not supplied

Applicability of the International Classification of Nursing Practice (ICNP) in the areas of nutrition and skin care.

PURPOSE: To evaluate completeness, granularity, multiple axial content, and clinical utility of the beta version of the ICNP in the context of standardized nursing care planning in a clinical setting. METHODS: An 35-bed acute care ward for infectious diseases at a Swedish university hospital was selected for clinical testing. A convenience sample of 56 patient records with data on nutrition and skin care was analyzed and mapped to the ICNP. FINDINGS: Using the ICNP terminology, 59%-62% of the record content describing nursing phenomena and 30%-44% of the nursing interventions in the areas of nutrition and skin care could be expressed satisfactorily. For about a quarter of the content describing nursing phenomena and interventions, no corresponding ICNP term was found. CONCLUSIONS: The ICNP needs to be further developed to allow representation of the entire range of nursing care. Terms need to be developed to express patient participation and preferences, normal conditions, qualitative dimensions and characteristics, nonhuman focus, and duration. PRACTICE IMPLICATIONS: The practical usefulness of the ICNP needs further testing before conclusions about its clinical benefits can be determined.

Acute Disease↗
PubMedDate not supplied

Quality of nursing diagnoses: evaluation of an educational intervention.

PURPOSE: To investigate the effects on the quality of nursing diagnostic statements in patient records after education in the nursing process and implementation of new forms for recording. METHODS: Quasi-experimental design. Randomly selected patient records reviewed before and after intervention from one experimental unit (n = 70) and three control units (n = 70). A scale with 14 characteristics pertaining to nursing diagnoses was developed and used together with the instrument (CAT-CH-ING) for record review. FINDINGS: Quality of nursing diagnostic statements improved in the experimental unit, whereas no improvement was found in the control units. Serious flaws in the use of the etiology component were found. CONCLUSION. Nurses must be more concerned with the accuracy and quality of the nursing diagnoses and the etiology component needs to be given special attention. PRACTICE IMPLICATIONS: Education of RNs in nursing diagnostic statements and peer review using standardized evaluation instruments can be means to further enhance RNs' documentation practice.

Education, Nursing, Continuing↗