Operational Design for Standardization and Computerization of a Data Based Nursing Diagnoses Schemata

摘要

This project was to develop two clinical tools. One, to categorize data by a nationally recognized schema and, the second, to connect that data to established nursing diagnoses. The link for the data collection base and the standards of care will be the developed computerized menu of nursing diagnoses. This menu has been synthesized from multiple references and represents the current state of the development of diagnostic statements. It includes those diagnostic statements recognized currently by the A.N.A., those proposed for recognition and current statements being developed within nursing. Although there are clear limitations to this program the sole purpose of its development was to provide a beginning tool for the systematic use of nursing diagnoses in clinical practice. The utilization of both programs assumes that there will be ongoing staff development in data collection as well as, assistance in making the cognitive connections from data to diagnosis. Both menus have been linked by a numerical code that in the future can easily be programmed for computerization. Concurrently, when the standards of care are developed they will follow the same numerical coding and be presented with each behavioral indice that is entered into the original data set. At present both tools can be used as an evaluative tool by the nurse and then, scanned by the nurse for a corresponding set of diagnoses.