摘要
目的:探索临床照护分类系统(CCC)在骨科护理实践中的应用。方法:使用CCC全智能护理信息系统对研究期间的骨科护理记录进行分析,研究数据包括2019年3-7月期间的所有护理记录,共计263402项护理记录。结果:从CCC系统中提取整理数据显示,患者护理诊断4种健康形态分类中,功能性要素占59.99%,生理性要素占26.41%,健康行为要素占9.32%,心理性要素占4.28%;21个照护要素中皮肤完整性方面涉及的护理措施最多(25.47%),其次是活动类(22.25%)、安全类(15.58%)、身体调节类(14.16%);评估监测类的护理措施占到了一半以上(50.88%),护理执行类的护理措施占27.43%,而教导指导、管理转介类的措施分别占12.03%和9.66%;护理预期目标与实际结局有统计学差异(P<0.01)。结论:临床照护分类系统(CCC)可以在骨科病房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,且能够为患者提供个性化的护理照护,也能分析每项护理内容的频率和次数,同时能够减少临床护理人员护理文书记录的工作量,有利于护理大数据的建立与分析。应用临床照护分类系统有助于促进骨科护理临床实践和护理科研的开展。
Objective:To explore the application of Clinical Care Classification(CCC)system in orthopedic nursing practice.Methods:The data of the nursing care records using the CCC Full Intelligent Care Information System from March 2019 to July 2019 were analyzed with a total of 263,402 nursing document entries.Results:The data from the CCC system showed that in the nursing diagnosis,the physiological factors accounting for 59.99%,the functional factors accounting for 26.41%,the healthy behavior factors accounting for 9.32%,and the psychological factors accounting for 4.28%.The care measures involved in the integrity of the skin among the nursing elements were the highest(25.47%),followed by the active category(22.25%),the safety category(15.58%)and the body regulation category(14.16%),of which the assessment monitoring category accounted for more than half of the total care measures(50.88%).Nursing implementation measures accounted for 27.43%,while teaching guidance and management referral category measures accounted for 12.03%and 9.66%,respectively;There were significant statistical differences between the expected goal of nursing and the actual outcome.Conclusion:The CCC can be used to record nursing data and write electronic medical records in intensive care unit practice,and can provide personalized care for patients,analyze frequency of each care content,and reduce the amount of work recorded by clinical nurses in nursing documents.It is beneficial to the establishment and analysis of big data in nursing.The application of CCC can promote the clinical practice of orthopedic nursing and the development of nursing research.
作者
韩海燕
高秀秀
杨磊
丛培珑
HAN Haiyan;GAO Xiuxiu;YANG Lei;CONG Peilong(Orthopaedics Department,He’nan Hongli Hospital,He'nan province,453400,China)
出处
《中国护理管理》
CSCD
北大核心
2020年第6期911-916,共6页
Chinese Nursing Management
关键词
临床照护分类系统
护理术语
骨科
护理实践
Clinical Care Classification
nursing terminology
orthopedic ward
nursing practice
