为紧急护理单位制定护理记录标准
Dilzilene Cunha Sivirino Farias1, Eliane de Fátima Almeida Lima1, Karla de Melo Batista1
1Universidade Federal do Espírito Santo, Vitória, ES. Brazil.
Revista da Escola de Enfermagem da U S P
|May 30, 2023
概括
制定了紧急护理单位的新注册标准,包括标准化的护理诊断,结果和干预措施. 本标准通过相关的,基于证据的术语来增强紧急护理实践.
科学领域:
- 护理 护理 护理
- 医疗信息学 医疗信息学
- 紧急医疗 紧急医疗
背景情况:
- 标准化术语对于医疗保健中的有效沟通和数据管理至关重要.
- 现有的护理术语可能无法完全捕捉紧急护理的复杂性.
研究的目的:
- 为紧急护理单位制定一个全面的注册标准.
- 该标准包括护理诊断,结果和干预措施.
主要方法:
- 应用研究涉及技术开发,分三个阶段进行.
- 声明是根据国际护理实践分类 (ICNP) 编制的.
- 经验丰富的急诊护士评估了诊断和结果的相关性.
主要成果:
- 准备了185个护理诊断,其中124个 (67%) 与ICNP一致.
- 143 (77%) 的诊断被护士认为是相关的.
- 495个护理干预与开发的诊断/结果相关.
结论:
- 成功建立了紧急护理单位的注册标准.
- 该标准使用标准化术语用于护理诊断/结果和干预措施.
- 开发的标准适用于紧急情况下的护理实践.
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