Purpose: The purpose of the study is (a) to describe care needs derived from records of patients in Dutch hospitals, and (b) to evaluate whether nurses employed the NANDA-I classification to formulate patients' care needs.
Methods: A stratified cross-sectional random-sampling nursing documentation audit was conducted employing the D-Catch instrument in 10 hospitals comprising 37 wards.
Findings: The most prevalent nursing diagnoses were acute pain, nausea, fatigue, and risk for impaired skin integrity.
Conclusions: Most care needs were determined in physiological health patterns and few in psychosocial patterns.
Implications for nursing practice: To perform effective interventions leading to high-quality nursing-sensitive outcomes, nurses should also diagnose patients' care needs in the health management, value-belief, and coping stress patterns.
Keywords: NANDA-I classification; nursing diagnosis; nursing documentation; record review.
© 2014 NANDA International, Inc.