临床照护分类系统在综合ICU护理实践中的应用分析与展望

doi:10.3761/j.issn.0254-1769.2020.03.015

摘要/Abstract

摘要：

目的探索临床照护分类系统（Clinical Care Classification System,CCC）在综合ICU护理实践中的应用情况。方法使用CCC全智能护理信息系统（以下简称CCC系统）对研究期间的护理记录进行分析,研究数据包括2019年3月—7月的所有护理记录,共计301 358项护理文件条目。结果从CCC系统中提取的数据显示,患者出现的护理诊断中,生理性要素占45.14%,功能性要素占41.62%,健康行为要素占12.33%,心理性要素占0.91%;照护要素分类中皮肤完整性方面涉及的护理措施最多（24.67%）,其次是活动类（21.55%）、安全类（15.09%）、身体调节类（13.72%）,其中评估监测类的护理措施占总护理措施的一半以上（52.39%）,护理执行类的护理措施占26.56%,而教导指导、管理转介类的措施分别占11.68%和9.36%;护理实际结局与预期护理目标比较,差异有统计学意义（P<0.05）。结论 CCC能够在为重症监护病房的患者提供个性化的临床护理实践中用于记录护理数据和书写护理电子病历,也能分析每项护理措施的频率和次数,有利于护理大数据的分析与应用;应用CCC可以促进综合ICU开展临床护理实践和护理科研。

关键词: 临床照护分类系统, 护理术语, 综合ICU, 护理, 护理信息学

Abstract:

Objective To explore the application of clinical care classification（CCC） intelligent nursing information systems in the practice of intensive care nursing. Methods The CCC intelligent nursing information system was used to analyze the nursing care records during the study. The study data included all nursing records from March 2019 to July 2019,for a total of 301,358 care document entries. Results The data collected from the CCC intelligent nursing information system showed that among the nursing diagnosis of patients,physiological factors accounted for 45.14%,functional factors accounted for 41.62%,health behavior factors accounted for 12.33%,and psychological factors accounted for 0.91%. Skin care in the classification involved the largest part of caring（24.67%）,followed by activity（21.55%）,safety（15.09%）,and body conditioning（13.72%）,of which the monitoring and monitoring measures accounted for the total care. More than half of the measures（52.39%）,nursing implementation measures accounted for 26.56%,while teaching guidance and management referrals accounted for 11.68% and 9.36%,respectively;there was a statistically significant difference between the actual nursing outcomes and the expected goals of care. Conclusion The CCC can be used to document nursing data and writing nursing care electronic records for individualized clinical Nursing practices in patients in intensive care unit. It can also be used analyze the frequency and frequency of each care content. Conducive to the establishment and analysis of nursing big data;the application of Clinical Care Classification system can promote the clinical nursing practice and nursing research in Intensive Care Unit.

Key words: Clinical Care Classification System, Nursing Terminology, Intensive Care Unit, Nursing Care, Nursing Informatics

纪小波, 曹串, 杨磊, 丛培珑. 临床照护分类系统在综合ICU护理实践中的应用分析与展望[J]. 中华护理杂志, 2020, 55(3): 391-396.

JI Xiaobo, CAO Chuan, YANG Lei, CONG Peilong. Analysis and prospect of applicating Clinical Care Classification System in nursing practice of intensive care unit[J]. Chinese Journal of Nursing, 2020, 55(3): 391-396.

图/表 7

表1 研究对象的一般资料（n=223）

表2 护理诊断的健康形态分布（n=20 972）

表3 护理诊断的照护要素分布（n=20 972）

表4 护理诊断分布（n=20 972）

表5 护理措施的照护要素分类（n=216 244）[次（百分比,%）]

表6 护理措施的类型分布（n=216 244）

表7 预期护理目标与实际护理评价比较（n=20 595）[频次（百分比,%）]

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