Electronic nursing care plans through the use of NANDA, NOC, and NIC taxonomies in community setting: A descriptive study in northern Italy.

Purpose: To carry on a descriptive analysis of nursing standardized language through the use of a software within outpatient facilities in northern Italy, organized according to the Chronic Care Model (CCM) and called Community Health Centers (CHC).

Methods: A descriptive design was adopted for the study. NANDA-I, NOC, and NIC taxonomies have been used to analyze care plans pulled from the software. Both qualitative and quantitative data were analyzed.

Findings: The average of nursing diagnosis correctly identified with respect to the nursing assessment is 83.7% (SD 29.9%). Class 4 diagnoses from Domains 4 have been identified as the most prevalent (22.4%), followed by risk for unstable blood glucose level 00179 (16.4%) and risk for overweight 00234 (13%). The main nursing outcomes were vital signs 0802 (22.5%), blood glucose level 2300 (16%), and weight loss behavior 1627 (11%). The most prevalent nursing interventions are wound care 3660 (27%), medication administration: intramuscular 2313 (19%), and health education 5510 (14%). The analysis shows ability in identifying nursing diagnoses, but a larger variability with outcomes and interventions. The study highlights the nursing role within CHC and identifies the main areas of expertise in chronic disease management: prevention and health education.

Conclusions: Nurses' role is fundamental for chronic disease management within CHC; NANDA-I taxonomy helps to analyze care plans.

Implications For Nursing Practice: - A taxonomy such as NANDA-I represents a valid opportunity to make more visible how much nursing skills affect the achievement of a higher level of health in chronic patients. - This study is useful in the further training of outpatient nurses who works in CHC. - The study represents the starting point for future research to deepen the development of a standardized nursing language in outpatient facilities.