J Korean Acad Nurs.  2005 Jun;35(3):441-450.

Comparison of Cancer Nursing Interventions Recorded in Nursing Notes with Nursing Interventions Perceived by Nurses of an Oncology Unit: Patients with Terminal Cancer

• Choi JY
• Jang KS

Abstract

PURPOSE: The purposes of this study were to determine the core nursing interventions in nursing notes and the practice which was perceived by nurses of an oncology unit with patients with terminal cancer. Also, comparing interventions in nursing notes with interventions in perceived practice was done. METHOD: Subjects were 44 nursing records of patients with terminal cancer who had died from Jan. to Dec. 2002 at C University Hospital and 83 nurses who were working on an oncology unit for more than one year. Data was collected using a Nursing Interventions Classification and analyzed by means of mean and t-test. RESULTS: The most frequent nursing intervention was 'nausea management' in the nursing note and was 'medication administration : oral' in perceived practice. The frequency of nursing interventions in the nursing record was lower than in perceived practice. CONCLUSION: This study finds that nurses actually practice nursing care, but they may omit records. To correct for omitted nursing records, development of a systematic nursing record system, continuous education and feedback is recommended.

Keyword

Interventions; Documentation; Perception; Terminal care; Cancer

MeSH Terms

*Terminal Care
Palliative Care
*Oncologic Nursing
*Nursing Records
Nursing Care
Neoplasms/*nursing
Middle Aged
Male
Korea
Humans
Female
Aged