ABSTRACT
The objectives of this study were: A) to assemble a Standard Care Plan Guide taken from both nursing care records as well as data from a bibliography review; B) to know the number of nursing interventions and evaluate their suitability according to the stated nursing diagnosis. These results can then be compared before and after using the Standard Care Plan Guide. An analysis of 1827 nursing care records was performed. The first phase, after studying 1255 records, consisted of standardizing the care to correspond with 36 nursing diagnoses previously selected from the NANDA taxonomy. The second phase saw the standard care practice incorporated by the nursing staff. And finally, a comparison was made of the results between phase one and three (before and after the incorporation of the Standard Care Plan Guide.) The number of nursing interventions notably increased, jumping from 3263 in the first phase up to 4271 in the third. The average nursing action per patient rose from 3.03 to 9.09. Also, the diagnostic categories increased, going from 930 in the first phase up to 1624 in the third. The average number of correctly stated diagnoses per patient climbed from 1.56 to 2.78. The authors state that better nursing care and attention to the patient can occur if the nurses are given the conceptual instruments and training that will facilitate their daily tasks.
