Danilo Mencigar, Biljana Prinčič
UKC Ljubljana, Marand engineering (Slovenija)
pediatric patient, cardiovascular critical care, nursing process, electronic health record, quality improvement
''6. Međunarodni kongres HDMSARIST-a''
Šibenik, 25.-28. travnja 2013. godine
Introduction: Nursing process is a deliberate problem solving approach to
the health care and nursing needs of patients. Nursing care is
implemented according to the care plan, so continuity of care for the
patient during hospitalization in intensive care unit (ICU) and in preparation
for discharge needs to be assured. The nursing diagnosis is the nurse
clinical judgment about the patient response to actual or potential health
conditions or needs. Cardiovascular critical care represents the most
demanding form of treatment, which may include management with
medications, open heart surgery to repair or resect and vital functions
support. The clinical information system called Think!Med Clinical™ at the
University Children’s Hospital Ljubljana includes tools allowing nurses to
better manage their workload, facilitate care planning and focus on making
the right care decisions. Now is time to integrate nursing care process
within the electronic health record (EHR).
Methods: This article is based on literature review and our clinical
experiences with e-documentation development. The prototype module of
nursing process was implemented, tested in clinical practice and critically
evaluated.
Conclusions: This new tool with decision making process enables nurses
to focus on improving quality and effectiveness of the health care in
Pediatric intensive care unit which is part of the Department for pediatric
surgery and intensive care. This will also affect on work organization and
communication, increasing patient safety and time saving.