Nursing assessment and care plan statements.

Abstract

Scope, specificity, and interrelatedness of patient problem and nursing intervention statements on nursing care plans were studied in relation to the introduction into the nursing assessment process of an objective observation checklist and a nursing history form. Ninety nursing care plans from six inpatient units in a Veterans Administration hospital were studied over an 11-month period. Results indicated that significant increases in the numbers of both types of care plan statements occurred only following the introduction of the nursing history, as did the numbers of nursing interventions related to the identified patient problems. The degree of specificity among the problem statements increased, but nursing interventions tended to become less explicit. The scope of focus of both types of statements continued to be primarily physical in orientation. The findings also suggested that, since the care plans reflected less than half the patient problems identified on the nursing histories, care plan studies alone might not be appropriate for evaluating the breadth of nursing care planning.