Development of Nursing Documentation for Patients Care in Post-Anesthesia Care Unit: Mahasarakham Hospital

Abstract

Objectives : To develop Nursing Documentation for Patients in Post-Anesthesia Care Unit, Mahasarakham Hospital.

Method : This study is research and development. By using the conceptual framework according to the nursing process. The research process was divide into 3 phases: situation analysis, developing nursing Doceumentation, and evaluation. Sample were 6 Anesthesiologists and 25 Nurse Anesthetists were included by purposive sampling. The research instruments were: 1) nursing documentation for patients in Post-Anesthesia Care Unit, 2) checklist of nursing documentation’s quality, and 3) satisfaction
questionnaire regarding nursing documentation. The reliability of questionnaire was 0.93. The data were analyzed using percentage, mean, and content analysis.

Results : The nursing documentation was developed using structural-type. The checklist and narrati ve were used. The documentation form and signatures was improved clearly. The assessment data were added consisting 1) diagnosis and Anesthesiologist’s name, 2) the results of EKG, CVP, SpO2, respiration rate, conscious, muscle power, bladder full, nausea/vomiting and discharging criteria, 3) implementation of using opioid drugs (last dose) and fluid/blood infusion, and 4) the evaluation of
vital signs and conscious in the early phase and before discharge phase. Nursing documentation’s quality and satisfaction regarding nursing documentation, both of the overall percentage were high level.

Conclusion : Nursing documentation can be used to assess the problems /complications of patients in a comprehensive way, which leads to more proper, timely and safety care.