Cross-Mapping ICNP Terms with Taiwanese Gynecological Nursing Records

驗證國際護理作業分類系統在台灣婦科護理記錄之適用性

郭春花(Chun-Hua Kuo) ； 顏妙芬(Miao-Fen Yen)

《The Journal of Nursing Research》 14卷4期 (2006/12) Pp. 271-278

摘要

本研究主要目的在探討國際護理作業分類系統(ICNP)Beta2中譯版在婦科護理記錄之適用性，採病歷查閱方式，於2004年7月至8月在台灣南部某區域教學醫院婦科進行研究，以中文ICNP Beta 2瀏覽軟體轉譯病歷中護理記錄，當護理記錄內容呈現飽和、不再有新內容出現時即行停止。研究分析62本病歷，共轉譯6,327句，其中護理現象1,918句(30.3%)，護理行動4,409句(69.7%)，二者比例為1:2.3。護理行動之字句多於護理現象。依適用性分析，能字詞完全符合2,041句(32.3%)、字意相符2,457句(38.8%)、需輸入字句1,663句(26.3%)、無法轉譯166句(2.6%)。護理現象前十項為：急性疼痛、體溫過高、意識狀態改變、潛在危險性感染、精神安適改變、腸胃功能障礙、排尿型態改變、焦慮、腹瀉、潛在危險性活動無耐力。護理活動前十項依序為：觀察開刀傷口、監測生命徵象、觀察病人精神狀態、口服藥使用、安排各項檢查、預防傷口感染、觀察尿管和尿液、觀察陰道引流管之分泌物、手術前後衛教、出院護理指導。研究結果顯示大多數護理記錄字句能以ICNP轉譯，建議在不同等級醫院之婦科作更多臨床驗證。

關鍵字

驗證 ； 國際護理作業分類系統 ； 護理記錄 ； 適用性

並列摘要

Cross-mapping the terms of International Classification for Nursing Practice (ICNP) with the handwritten nursing records of gynecological patients at one district of private teaching hospital in the south of Taiwan was conducted in July and August, 2004. The purpose of this study was to validate the applicability of ICNP for electronic nursing records in a gynecological setting. A Chinese version of the ICNP beta 2 browser was used to code nursing record sentences. Medical charts were reviewed until data were saturated. A total of sixty-two patient records were analyzed, producing 6,327 sentences, this included 1,918 sentences on nursing phenomena (30.3%) and 4,409 sentences on nursing action (69.7%). The ratio between the two was about 1:2.3. Coded sentences were compared according to the four levels of applicability with the original records, each was identified as a ”perfect fit”, ”conceptual fit”, ”partial fit”, or ”unable to fit”. Of the 6,327 sentences, 2,041 (32.3%) were designated as ”perfect fit”, 2,457 (38.8%) as ”conceptual fit”, 1,663 (26.3%) as ”partial fit”, and 166 (2.6%) as ”unable to fit”. The top ten most described nursing phenomena included: acute pain, high temperature, conscious change, potential infection risk, state of mind change, potential risk patient's mobility change endurance level, gastrointestinal function obstacles, changes in urination, anxiety, and diarrhea. The top ten most described nursing actions included: observe surgical wounds, monitor vital signs, changes of mentality, instruction on medication, arranging clinical check ups, wound infection prevention, urinary drainage tube and urine nature observation, checking for vaginal drainage, pre/post-operative healthcare, and discharge planning. Study results indicated that 71.1% of sentences could be cross-mapped. Further validation is suggested to validate ICNP in other gynecological hospitals.

並列關鍵字

cross-mapping ； International Classification for Nursing Practice ICNP ； nursing records ； applicability

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