Hefferin E A, Hunter R E
Nurs Res. 1975 Sep-Oct;24(5):360-6.
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.
针对患者问题陈述与护理干预陈述在护理计划中的范围、特异性及相互关联性，研究了其与在护理评估过程中引入客观观察清单及护理病史表格之间的关系。在11个月的时间里，对一家退伍军人管理局医院六个住院科室的90份护理计划进行了研究。结果表明，仅在引入护理病史之后，两种护理计划陈述的数量都显著增加，与所确定的患者问题相关的护理干预数量也是如此。问题陈述之间的特异性程度有所提高，但护理干预往往变得不那么明确。两种陈述的关注范围在方向上仍然主要是身体方面的。研究结果还表明，由于护理计划所反映的患者问题不到护理病史中所确定问题的一半，仅进行护理计划研究可能不适用于评估护理计划的广度。
