Date of Award

Spring 1986

Degree Type

Thesis - Restricted

Degree Name

Master of Science (MS)

Department

Nursing

Abstract

The purpose of this study was to determine if an operational definition and guidelines for the formulation of nursing diagnoses had an impact on the use of nursing diagnoses in the clinical setting. The charts of 45 patients were reviewed to obtain nursing diagnoses written prior to the implementation and 45 charts were reviewed after implementation. The 45 charts represent 5 charts from nine patient care areas. This review resulted in 62 nursing diagnoses in Group A (before) and 58 nursing diagnoses in Group B (after). The diagnostic statements were evaluated using the Nursing Diagnoses Evaluation Forms designed for this study. Reliability and validity of this tool was tested. The percentage of nursing diagnoses with a perfect score of 5 for Group A was 55% and for Group B 59%, this difference was not statistically significant. The critical care and nursery patient care areas were the only areas to have a mean score of less than 4.00 for Group A. The critical care patient care area had a significant increase in the mean score of nursing diagnoses from Group A to Group B. This represents the only significant finding in this study. Altered comfort, anxiety, knowledge deficit, and impaired mobility were the most frequently used diagnoses in each Group. A significantly greater number of the nursing diagnoses could be categorized under one of the eleven Functional Health Patterns after the implementation of an operational definition and guidelines for the formulation of nursing diagnoses. No nursing diagnoses were identified for either group for the value-belief, sexuality-reproduction, or sleep rest patterns. The researcher concluded that the operational definition and guidelines for the formulation of nursing diagnoses provide a more clear picture of nursing diagnoses, which represents one component of nursing practice. This is supported by the results which indicate that all of the nursing diagnoses could be categorized under one of the functional health patterns for Group A. In Group A there were general nursing diagnoses written that related to the medical model, no such diagnoses were written for Group B. The conclusion is further supported by the results that indicate an increase in mean scores for nursing diagnoses written in critical care after the implementation. Critical care nurses have difficulty trying to describe what they do that is separate or unique from medicine. The guidelines developed by the cooperating agency provide a method for nurses to document nursing activities that relate to medical diagnoses separate from nursing.

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