Abstract

• Purpose
  The purposes of this study were to determine the core nursing interventions in nursing notes and the practice which was perceived by nurses of an oncology unit with patients with terminal cancer. Also, comparing interventions in nursing notes with interventions in perceived practice was done.
• Method
  Subjects were 44 nursing records of patients with terminal cancer who had died from Jan. to Dec. 2002 at C University Hospital and 83 nurses who were working on an oncology unit for more than one year. Data was collected using a Nursing Interventions Classification and analyzed by means of mean and t-test.
• Results
  The most frequent nursing intervention was ‘nausea management’ in the nursing note and was ‘medication administration : oral’ in perceived practice. The frequency of nursing interventions in the nursing record was lower than in perceived practice.
• Conclusion
  This study finds that nurses actually practice nursing care, but they may omit records. To correct for omitted nursing records, development of a systematic nursing record system, continuous education and feedback is recommended.
• Keywords: Interventions; Documentation; Perception; Terminal care; Cancer

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