A Comparison of Interventions Recorded in Nursing Notes between Actue and Subacute Stage after a Cerebrovascular Accident

Choi, Ja Yun; Park, Soon Joo

Abstract

PURPOSE: This study aimed to: 1) determine the core nursing interventions, and 2) compare acute interventions with subacute interventions recorded in the nursing notes of patients with cerebrovascular accidents (CVA). METHODS: The nursing records covering the first 10 days of 30 patients with a CVA who were admitted from January to December 2004 at C University Hospital in Korea were examined. Data was collected using the nursing interventions classification (NIC) from January to April 2005. Finally, data analysis was carried out using mean, SD, and paired t-test according to domains, classes, and interventions. RESULTS: The most frequent nursing intervention at both stage was "Neurologic monitoring". There were differences in interventions belonging to the "Physiological: complex," "Behavioral," "Safety," and "Health system" domains between the acute and subacute stages. The frequency of interventions belonging to the "Immobility management," "Neurological management," "Tissue perfusion management," "Patient education," "Risk management," "Health system mediation," and "Information management" classes at the acute stage was higher compared to the subacute stage. CONCLUSIONS: This study found out that nurses relatively recorded more nursing interventions during the acute stage hence the unsuccessful documentation of the subacute stage particularly in describing the specific nursing interventions at this stage.