Purpose: To identify nursing diagnoses, interventions, and outcomes used with patients undergoing abdominal surgery, and the links among them.
Methods: A review of the nursing records of 60 patients undergoing abdominal surgery. Three checklists developed by the researchers were used to document nursing diagnoses made, interventions specified, and outcomes selected.
Findings: Pain was the most frequent diagnosis, "pain management" the most frequent intervention, and Pain Level the most frequent outcome. Further study is needed with various samples and settings.
Conclusions: Most of the suggested NIC-NANDA interventions and NOC-NANDA outcomes listed in NANDA Nursing Diagnoses: Definitions and Classification, 1999-2000, were used in this study, but some additional interventions and outcomes should be considered for inclusion.
Practice Implications: This study provides a framework for documenting nurses' work; the results of the study can promote more rapid computerization of nursing records.
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