From nursing care sheets to nursing diagnoses

Objective. The aims of this descriptive analytical study were: aa) to classify the expressions used by nurses in their care plans at the Alicante General Hospital (HGUA) in a theoretical categories system designed for a pilot study by a research group; b) to analyze the pre-diagnosis expressions used by nurses in their nursing records, and c) to identify the most frequent nursing diagnoses in the HGUA through the activities recorded in care plans. Method. There were 401 nursing care sheets. Regarding the study variables, 22 theoretical categories and prediagnosis expressions were recorded by nurses. The contents of care plans were analyzed and expressions were grouped within the categories system. Results. There were 5,589 entries. The most frequent categories were monitoring of vital signs, drug administration, general well-being, and diagnostic tests. Thirty-three diagnostic expressions were identified from 656 pre-diagnosis expressions analyzed. The most frequent were: risk of infection (26.07%), acute pain (19.97%), and deterioration of tissue/skin integrity (13.11%). The analysis of entries reflected the culture and values of the profession, which should be taken into consideration when implementing changes in organization of work in the HGUA.