護理過程支援資訊系統-入院評估表單

Supporting Nursing Process with Nursing Information Systems–based on Admission Assessment

江志偉(Chin-Wei Chiang)

指導教授 ： 劉建財

臺北醫學大學/醫學院/醫學資訊研究所/碩士(2008年)

摘要

臨床上護理人員在制定護理計劃時，需要參照許多的書籍，包括護理診斷、護理結果、護理措施等書，而2007-2008年時北美護理診斷協會(NANDA)的護理診斷已發展到有187個項目，護理敏感之病患結果分類(NOC)有330個，護理措施分類(NIC)也有542個，如此多的項目跟分類，要能夠正確的使用，將有其難度。本研究主要目的為發展護理過程輔助系統，以期減少護理人員文書作業，提高記錄的正確性和時效性，以及增加病患直接護理時間。依照護理臨床實務藉由護理人員的臨床評估，由入院評估表單(結合三家醫學中心及護理診斷手冊)進入護理診斷及護理診斷之定義特徵，再連結至護理敏感之病患結果分類與護理措施分類，系統用結構化查詢語言（Structured Query Language, SQL）資料庫，以動態伺服器網頁（Active Server Pages, ASP）呈現，使用者根據系統輔助判斷與決定之後完成病人之臨床照護計畫。將臨床評估填進入院評估表單內後，本研究所設計的系統會將所填項目轉換至定義性特徵，並將定義性特徵所占的百分比及數量顯示提供參考，護理人員依照所建議的定義性特徵決定護理診斷，配合臨床的經驗與判斷，為該病人建立詳細的護理計劃，護理人員可即隨時列印該病人護理計劃，實行護理措施。在訂立護理計畫的整個過程中，記錄所有選項，在未來將提供電腦建議護理診斷準確度的參考。而在輸出資訊方面除了將護理計畫整理並列表外，系統所採用的是國際通用編碼，只須將所實施的護理措施做一轉換，輸出相對的編碼，就能夠完成。本次研究雖然以入院護理評估表單為主，但其模式可以延伸至其他不同科別之護理評估表單，只要該科別護理評估表單，將其個別詳細項目與定義性特徵連結，如此便可藉由定義性特徵與護理診斷資料庫連結，同樣可以做出建議性診斷與決策，讓護理人員作為臨床決策的參考。另外，電子化的護理照護也可藉由個案模擬過程，提供新進人員及護生，一個數位學習的管道，將有助於護理教育的發展與應用。

關鍵字

護理計畫 ； 護理診斷 ； 護理過程 ； 入院護理評估

並列摘要

The nursing staff needs to consult a lot of books while making a health care plan, including nursing diagnosis, nursing-sensitive patient outcomes classification (NOC), nursing interventions classification (NIC) and so on. NANDA(North American Nursing Diagnosis Association)have published 187 nursing diagnoses in year 2007-2008, The Center for Nursing Classification & Clinical Effectiveness at the College of Nursing, The University of Iowa have published 330 NOC, and 542 NIC. It is very difficult to link them together at point of care. The purposes of this research are to develop a decision support system to help decision making in nursing diagnosis, nursing outcomes classification, nursing intervention and nursing documentation. The system can then be expected to reduce nursing staff's workload in documentation, to improve exactness and timeliness in writing nursing records, and to increase time for patient’ care. As a part of the admission assessment the primary nurse determines the nursing orders based on the signs, symptoms, diagnoses, and expected outcomes, then decides the interventions of the care plan. The admission assessment data are also input to the system, which map them into the corresponding defining characteristics, and produces a list of suggested nursing diagnoses. Each suggested diagnose is associated with the percentage of matched defining characteristics for that diagnose. A nurse can select the appropriate one(s) or add new one(s) if they are not in the suggestion list. After, choosing the nursing diagnoses, the system can link the diagnoses to the expected patient outcomes and interventions that make up the health care plan. With the help of the system, nurses can use their expertise through critical thinking to make nursing diagnoses and care plans. The system has been designed based on admission assessment data, which based on admission assessment data, which can easily be extended to other forms of nursing assessment. The computerized nursing care plans can be used to create study cases for e-learning in support of nursing education.

並列關鍵字

Care Plan ； Nursing Diagnosis ； Nursing Process ； Admission Assessment

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