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Capturing Key NANDA-I Nursing Diagnoses From Actual Clinical Data for Patients With Heart Failure.

PURPOSE: The purpose of the study was to identify key nursing diagnoses with related factors and signs/symptoms using NANDA-I for patients with heart failure (HF).

METHODS: A retrospective descriptive design was used to address the research questions. Data were obtained from the records of patients discharged for 1 year with the medical diagnoses of HF from a Midwestern community hospital. A total of 272 inpatient records were analyzed to describe the frequency and percentage of NANDA-I diagnosis with related factors and signs/symptoms.

RESULTS: The top 10 NANDA-I diagnoses associated with related factors and signs/symptoms were identified.

CONCLUSION: Further research related to standardized nursing terminologies such as NANDA-I using large clinical databases from health information systems is needed to support evidence-based nursing diagnosis decision making.

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