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Related Experiment Videos

Nursing assessment and care plan statements.

E A Hefferin, R E Hunter

    Nursing Research
    |September 1, 1975
    PubMed
    Summary
    This summary is machine-generated.

    Introducing a nursing history form improved nursing care plans by increasing patient problem and nursing intervention statements. However, interventions became less explicit, and care plans still primarily focused on physical aspects.

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    Area of Science:

    • Nursing
    • Healthcare Informatics
    • Patient Care Management

    Background:

    • Nursing care plans are crucial for structured patient care.
    • The effectiveness of nursing care plans can be influenced by the assessment tools used.
    • Evaluating the quality of nursing documentation is essential for quality improvement.

    Purpose of the Study:

    • To examine the impact of introducing an objective observation checklist and a nursing history form on nursing care plans.
    • To assess changes in the scope, specificity, and interrelatedness of patient problem and nursing intervention statements.
    • To evaluate the comprehensiveness of nursing care planning.

    Main Methods:

    • A study of 90 nursing care plans across six inpatient units over 11 months.

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  • Comparison of care plans before and after the introduction of new assessment tools.
  • Analysis of patient problem statements and nursing intervention statements for scope, specificity, and relationship.

    • Main Results:

    • The introduction of the nursing history form significantly increased the number of patient problem and nursing intervention statements.
    • Specificity of problem statements improved, but nursing interventions became less explicit.
    • Both problem and intervention statements predominantly focused on physical health needs.

    Conclusions:

    • The nursing history form positively impacted the quantity and specificity of nursing care plan content.
    • Nursing interventions require further refinement to ensure explicitness and clarity.
    • Nursing care plans may not fully represent the breadth of identified patient problems, suggesting limitations in using them for comprehensive evaluation.