基于临床护理分类系统的患儿体温过高护理程序知识库的构建

doi:10.3761/j.issn.0254-1769.2020.12.009

摘要/Abstract

摘要：

目的基于临床护理分类（clinical care classification,CCC）系统2.5版,构建患儿体温过高护理程序知识库。方法以患儿常见症状“腋下温度≥37.5 ℃”为研究内容,采用循证护理法,研究小组结合临床护理常规及医院管理制度,汇总与“腋下温度≥37.5 ℃”相关的所有护理措施。基于CCC系统2.5版“腋下温度≥37.5 ℃”相关护理诊断、核心护理干预措施、护理活动类型修饰语及护理结局修饰语,构建患儿体温过高护理程序知识库初稿。按照CCC系统2.5版中“具体护理措施编码=核心护理干预编码+护理活动类型修饰语编码”“护理结局编码=护理诊断编码+护理结局修饰语编码”的编码规则,对知识库初稿内容进行编码,然后通过专家咨询对知识库初稿内容及编码进行评价、讨论与修改,确定知识库终稿。结果患儿体温过高护理程序知识库终稿包括1项护理诊断、19项具体护理措施和4种护理结局。结论患儿体温过高护理程序知识库具有专业性、科学性与实用性,标准化了护理语言,有利于信息共享。

关键词: 标准化护理术语, 临床护理分类系统, 知识库, 儿科护理学

Abstract:

Objective To build a knowledge base of nursing procedures in pediatric hyperthermia based on Clinical Care Classification（CCC） 2.5 version. Methods With the common symptoms of pediatrics “axillary temperature≥37.5 ℃” as the research content,the research team summarized all the specific nursing measures related to "axillary temperature≥37.5 ℃" combined with clinical nursing routine and hospital management system based on CCC 2.5 version by evidence-based nursing method. Based on the definition of "axillary temperature≥37.5℃" related nursing diagnosis,core nursing interventions,modifiers of nursing activity types and modifiers of nursing outcomes in CCC 2.5,the first draft of knowledge base of "pediatric hyperthermia" nursing procedures was constructed.According to the coding rules of "code of specific nursing measures=code of core nursing interventions +code of modifiers of nursing activity type" and "code of nursing outcomes=code of nursing diagnosis+code of nursing outcome modifiers" in CCC 2.5,the first draft of the knowledge base was coded. After that,the expert consultation meeting was held to evaluate,discuss and revise the draft content and code of the knowledge base,and the final draft of the knowledge base was determined. Results The final draft of the knowledge base of pediatric "hyperthermia" nursing procedures includes 1 nursing diagnosis,19 specific nursing measures and 4 nursing outcomes. Conclusion The knowledge base of pediatric "hyperthermia" nursing procedures is professional,scientific and practical,which standardizes nursing language and facilitates information sharing.

Key words: Standardized Nursing Language, Clinical Care Classification, Knowledge Base, Pediatric Nursing

赵永信,顾莺,张晓波,刘芳,吴颖,叶岚,王慧美,万嫣敏,陆春梅,夏爱梅. 基于临床护理分类系统的患儿体温过高护理程序知识库的构建[J]. 中华护理杂志, 2020, 55(12): 1808-1812.

ZHAO Yongxin,GU Ying,ZHANG Xiaobo,LIU Fang,WU Ying,YE Lan,WANG Huimei,WAN Yanmin,LU Chunmei,XIA Aimei. Construction of nursing procedures knowledge base for pediatric hyperthermia based on clinical care classification[J]. Chinese Journal of Nursing, 2020, 55(12): 1808-1812.

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