护理措施分类用于儿童普外科护理记录的适用性研究

Mapping analysis of application of nursing interventions classification in pediatric general surgery nursing documentation

目的分析第6版护理措施分类在儿童普外科的临床适用性,为规范临床护理用语,促进护理措施标准化术语的临床使用提供依据。方法本研究的研究方法为映射法。选取上海交通大学医学院附属上海儿童医学中心普外科2018年10月1日至12月31日的电子护理记录,包括自由录入的护理措施记录和医嘱相关的护理措施记录。以概念一致性对比电子护理记录与标准化护理措施(第6版护理措施分类)的匹配程度。采用难度、耗时来分析匹配所得的标准化护理措施的特质。结果4560条独立的电子护理记录共映射所得7个领域的86条护理措施。其中,有98.84%(4507/4560)护理记录与护理措施完全匹配、0.83%(38/4560)护理记录与护理措施部分匹配、0.33%(15/4560)护理记录与护理措施不匹配。难度和耗时分别为(2.20±0.45)min和(2.03±1.25)min。结论护理措施分类可以用于描述儿童普外科护理人员的日常行为活动,还可以解决护理记录在呈现上的标准化问题,适合作为标准化的护理语言用于儿童普外科的护理记录。

Objective To analyze the clinical applicability of the sixth edition of nursing measures classification in children's general surgery,to provide a basis for standardizing clinical nursing terms and to promote the clinical use of standardized terminology of nursing measures.Methods The research method of this study was mapping method.The electronic nursing records of the general surgery of Shanghai Children′s Medical Center Affiliated to Shanghai Jiaotong University School of Medicine from October 1st to December 31st,2018,including the records of care records for free entry and the records of nursing measures related to medical orders were selected.The degree of matching between electronic care records and classification of nursing measures(sixth edition of nursing measures classification)was compared with conceptual consistency.Difficulties and time-consuming analysis of the characteristics of the standardized care measures obtained by matching.Results A total of 4560 independent electronic care records mapped 86 treatments in seven areas.Among them,98.84%(4507/4560)of the nursing records were completely matched with the nursing measures,0.83%(38/4560)of the nursing records were partially matched with the nursing measures,and 0.33%(15/4560)of the nursing records did not match the nursing measures.Difficulty and time-consuming were expressed as standard deviation,which were 2.20±0.45 and 2.03±1.25 respectively.Conclusions The classification of nursing measures can be used to describe the daily behavioral activities of the children's general surgery nurses,and can also solve the standardization problem of the nursing records in the presentation,and is suitable as a standardized nursing language for the nursing records of children's general surgery.