Prevalence and accuracy of nursing diagnoses in patients with malignant bronchial and lung cancer: A retrospective observational study

Purpose: To describe the prevalence and accuracy of nursing diagnoses (NDs) in adult patients with malignant bronchial and lung cancer. Methods: A retrospective, observational, monocentric study was conducted at the largest university hospital in Rome, Italy. Electronic health records (EHRs) of adult inpatients (≥18 years) hospitalized in 2022 with malignant bronchial and lung cancer were analyzed. NDs were documented using the Professional Assessment Instrument (PAI), a clinical nursing information system based on the Clinical Care Classification (CCC) standardized nursing terminology. The accuracy of nursing documentation was assessed with the D-Catch instrument, evaluating record structure, admission data, ND formulation, interventions, progress/outcome evaluations, and legibility. Descriptive statistics were used to analyze ND prevalence and documentation accuracy. Results: A total of 682 EHRs were examined, identifying 3510 NDs across 34 distinct labels. Patients had a mean of 5.15 NDs (SD: 2.99; range: 1–16). Ten high-frequency NDs were identified, with Infection Risk (76.7 %), Fall Risk (66.6 %), and Acute Pain (53.1 %) emerging as the most prevalent. Overall documentation accuracy was high across most dimensions; however, ND formulation showed comparatively lower accuracy (mean score: 6.38; SD: 0.98). Conclusions: Evaluating the prevalence and accuracy of nursing diagnoses enhances the understanding of the complex care needs of patients with malignant bronchial and lung cancer, a population marked by significant clinical vulnerability and multidimensional care requirements. Strengthening diagnostic reasoning—through structured documentation systems and continuous training—may improve care planning, facilitate interdisciplinary communication, and ultimately optimize patient outcomes.