神經外科護理計劃電腦化之實施概況探討

Implementation of a Computerized Nursing Care Strategy in Neurosurgery Patients

酒小蕙(Shiao-Hui Shiu) ； 陳真瑗(Delores Chen) ； 陳玉技(Yu-Chin Chen)

《醫護科技學刊》 2卷3期 (2000/07) Pp. 259-265

https://doi.org/10.6563/TJHS.2000.2(3).4

摘要

自1992年起某醫學中心使用護理計劃的電腦化，為評估其使用品質，採回溯性分析，自電腦資料庫中列印二年來神經外科護理計劃檔案資料，及橫斷式調查、在四個神經外科病房，隨機抽取住院三天以上的病患審核所建立的護理計劃並與照顧的護士會談， 以暸解護理人員應用護理計劃的品質。資料以頻率、百分比、排序，及χ2分析。結果發現：神經外科最常被使用的疾病診斷為顱內出血、最常用的護理診斷為高危險性感染、護理處置時間最長的為皮膚完整性受損、建立的疾病診斷被使用率為64.1%、相對應的護理問題一致性與實際應用的一致性達80%以上者為29.4%、24小時內即確立護理計劃者達99.1%、護理計劃的完整性以目標之設定完整性最高，導因之設定完整性最低，護理計劃內容完整性與護理人員的學歷、工作年資、職稱並無統計相關。

關鍵字

護理診斷 ； 護理計劃電腦化

並列摘要

A computerized nursing care strategy has been implemented for neurosurgey patients at a medical center since 1992. This study assesses how nursing staff can effectively utilize this computer program. The retrospective design was used in this survey. Two types of data were collected: (a) computer files from 1994 to 1996, in which random data were drawn from neurosurgery patients staying more than three days in four neurosurgery Wards and (b) interviews of nursing staff. Descriptive statistics methods were applied, such as frequency, percentage, and chi-square test. The results indicated that the conventional disease diagnosis is ICH while the conventional nursing diagnosis is high-risk infection. The nursing diagnosis of skin impairment takes the longest nursing time to be managed. The rate of utilizing pre-set disease diagnosis is 64.1 %. The percentage of completed nursing care plan in 24 hours after patient's admission to the ward is 99.1 %. In the nursing care strategy, the most completed part is identifying factors of nursing diagnosis. The completeness of a nursing care strategy is not correlated with the nursing staffs' education background, working experience and position.

並列關鍵字

nursing diagnosis computerized ； nursing care strategy