J Nurs Acad Soc.  1990 Dec;20(3):368-380.

A Study on the Development of Standardized Nursing Care Plans for Computerized Nursing Service

• Kim CJ
• Chun CY
• Lim YS
• Park JW

Abstract

A central issue in the development of nursing practice is to describe the phenomenon with which nursing is concerned. To identify the health problems which can be diagnosed and managed by the nurse is the first step to organize and managed by the nurse is the first step to organize and ensure the development of nursing science. Therefore the academic world has been discussing the application of the nursing diagnosis in nursing practice as a means of improving quality of care. The objectives of this study were to develop a standardized nursing care plan for ten selected nursing diagnoses to from a database for computerized nursing service. The research approach used in the study was (1) the selection of the ten nursing diagnoses which occur most frequently on medical-surgical wards, (2) the development of standardized nursing care plan for the ten selected nursing diagnoses, (3) application of the plan to hospitalized patients and evaluation of the content validity by the nurses, and (4) evaluation of the clinical effects after the use of the standardized nursing care plans. The subjects were 56 nurses and 395 hospitalized patients on two medical and two surgical unit. The results of this study were as follows ; 1) The ten selected nursing diagnoses for the development of the standardized nursing care plans were "PAIN, SLEEP DISTURBANCE, ALTERED HEALTH MAINTENANCE, ALTERATION IN NUTRITION, ANXIETY, CONSTIPATION, ALTERED PATTERNS OF URINARY ELIMINATION, DISTURBANCE IN BODY IMAGE, POTENTIAL FOR ACTIVITY INTOLERANCE AND ACTIVITY INTOLERANCE". 2) The developed standardized nursing care plans included the nursing diagnosis, definition, defining characteristics, etiologic or related factors that contribute to be condition, recording pattern desired out-comes and nursing orders(nursing interventions). 3. The plan was used with hospitalized patients on medical-surgical wards to test for content validity. The patient's satisfaction with the nursing care and nurses' job satisfaction were investigated to evaluate the clinical effects after the use of the standardized nursing care plans. A comparison of patient satisfaction with nursing care before and after the introduction of the standardized nursing care plans showed a statistically significant higher level of satisfaction with the standardized care plans. There was no difference in the level of job satisfaction expressed by the nursing staff before and after the standardized nursing care plans were introduced. However, when opinions about the use of the standardized nursing care plans were examined it was found that there was a positive effect on clarity in defining the nursing problems, determining nursing cost, more feasible goal setting, effective and systematic nursing records and indications for nursing research. The results of this study suggest that in order to increase the use of nursing diagnoses in the clinical area, it would be effective to select some wards as a pilot project, give the nurses training in the use of nursing diagnosis and develop and use the standardized nursing care plans. In addition to the ten diagnosis used in this study it sis recommended that continual development of nursing diagnoses be done using diagnoses that are appropriate to Korea and testing them for validity through standardized care plans.

MeSH Terms

Humans
*Nursing Care
Nursing Diagnosis
Nursing Service, Hospital/*organization & administration
*Patient Care Planning
*Therapy, Computer-Assisted