ABSTRACT
PURPOSE: The aim of this study was to describe the use of nursing terminologies in the care plans made for patients in a cardiology rehabilitation unit. METHODS: We retrospectively examined the clinical documentation for all patients admitted to a cardiology program in a small hospital in the northeast of Italy in 2008. FINDINGS: The sample included 76 patients (87% male) with an average age of 60 years. Care plans included 21 NANDA-I nursing diagnoses and three collaborative problems, 45 Nursing Outcomes Classifications (NOC) and 46 Nursing Intervention Classifications (NIC). The most frequent diagnoses were the following: decreased cardiac output, activity intolerance, and risk for or presence of imbalanced nutrition (more than body requirements). The prevalent outcomes were related to cardiopulmonary physiological health and knowledge about cardiac disease management and diet. The most frequent nursing interventions were the following: exercise promotion, energy management, weight management, medication management, cardiac precautions, cardiac care (rehabilitative), teaching (prescribed activity/exercise and diet), and vital signs monitoring. CONCLUSIONS AND IMPLICATIONS FOR NURSING PRACTICE: Nurses in rehabilitative cardiology care are aware of patients' problems, but projects can improve the coherence between concepts, the attention to psychological problems, and self-care.
