Nursing Diagnosis and Documentation

Evaluation of the nursing process utilization in a teaching hospital, Ogun State, Nigeria

Journal of Nursing and Midwifery Sciences · 2017

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Abstract

Context: Nursing process is the systematic method of thinking used by nurses to develop an individualized plan of care for patients. Effective use of the nursing process depends on a nurse's familiarity with the standardized nursing language. Aim: This study evaluates the utilization of nursing process on the day of admission and within 24 h of patient admission in a teaching hospital.Setting and Design: Descriptive and Retrospective design was utilized.Materials and Methods: Systematic sampling technique was adopted to evaluate 959 patients' records from 2014 to 2016 in 2 medical and 2 surgical wards over 3 months period using a self designed checklist.Statistical Analysis Used: Data collected was analyzed using SPSS version 21 and presented as frequencies and percentages. T test was used to test the significant difference between variables with P value set at ≤ 0.05.Results: Only 24.9% of the medical records contained the nursing process form. On the day of admission,

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