THE NURSING DIAGNOSIS WITH THE PES IN ELDERLY CARE

Author

S.E. Gutker de Geus, physical therapist, CareNext, Zevenaar, the Netherlands, sgutker@outlook.com

Introduction

Working methodically is obliged in the field of elderly care in the Netherlands. The aim of the study is to investigate whether nurses work methodically with a focus on the nursing diagnosis and the PES. The PES stands for Problem, Etiology and Signs and symptoms (defining characteristics). The classification used in this study is Mikzo, which is based on Nanda NOC NIC. The classification Mikzo has the nursing diagnoses with the PES incorporated.

Theory

In the nursing diagnosis the problem describes a lack in selfcare.

The etiology describes the cause of this problem.

The signs and symptoms (defining characteristics) are important to be able to describe the problem in detail. The PES is the heart of the nursing diagnosis.

Method

A qualitative design was used for this study using a document analysis of a sample of electronic health records in an elderly care organization. The aim of the document analysis was to research the actual use of the nursing diagnosis with the PES in elderly care.

• In the group with a problem with cognition and risk of mood swings 75% of the diagnoses in the EHR was substantiated with the PES. Causes that were mentioned are the type of dementia or the DSM5 diagnosis.

• In most of the records in the EHR (>60%) the nursing diagnosis with the PES was part of the care plan in the EHR.

Results Conclusion

• In a nursing home with 34 residents 24 residents were included because they had a care plan with the nursing diagnosis and 10 were excluded because they had a Omaha System plan without the nursing diagnosis and the PES. Of these 24 residents 15 had a problem with eating, drinking and danger of swallowing, 13 of them had a problem with mobility and risk of falling and 12 of them had a problem with cognition and risk of mood swings.

• In the group with eating, drinking and danger of swallowing 55% of the diagnoses in the EHR was substantiated with the PES. Several causes were mentioned like dementia, lack in mobility because of Parkinsonism, neuropathy or food that does not suit the cultural habits. This information is of great value for a suitable intervention.

• In the group with a problem with mobility and risk on falling 72% of the diagnoses in the EHR was substantiated with the PES. Causes that were mentioned are anxiety, heart failure, pain and paralysis after a stroke.

In most cases (>60%) the nursing diagnoses with the PES was described in the EHR.

Next question for research:

What is the added value of the nursing diagnosis with the PES?