印度尼西亚萨拉提加政府医院肺结核患者护理诊断的写作趋势、目的和结局标准

M. Rofi’i, B. Warsito, A. Santoso, Sara Ulliya
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摘要

背景。在护理文献中发现的护理目标和结果标准的书写差异很大且不恰当,需要对这一现象进行更深入的探讨。研究的目的是确定护理目标的书写和护理诊断的结果标准。方法。研究设计采用直接观察的定性研究方法。数据采集于耐多药结核病病房,样本为100例肺结核患者。抽样技术为非概率抽样。结果。气道清除无效的护理诊断目标是气道再次有效清除,问题得到解决,患者气道恢复正常,患者咳嗽恢复正常等。无效呼吸方式的护理诊断目标为有效呼吸方式、无效呼吸方式解决等。护理诊断气道清除无效的结局标准为:咳嗽阴性、呼吸频率正常、生命体征正常、痰液阴性、呼吸短促、咳嗽缓解、患者舒适、患者能有效表现咳嗽、痰液能排出、呼吸缓解、痰液能排出等。护理诊断无效呼吸方式的结局标准为呼吸频率正常、生命体征正常、呼吸频率为20 x/min、无虚弱、无恶心等。Recomendation。建议护士接受与护理诊断目标和结果标准相关的培训、社会化或讲习班,并应使用NANDA和NIC-NOC参考文献。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Nurse Trend in Writing Objectives and Outcome Criteria of Nursing Diagnosis in Patients With Pulmonary Tuberculosis at The Government Hospital in Salatiga Indonesia
Background. Writing nursing goals and outcome criteria found in nursing care documentation was very varied and not appropriately, it needs to be explored more deeply about the phenomenon. The Study objective was to determine the writing of nursing goals and the outcome criteria for nursing diagnoses. Methods. Research design was qualitative research with a direct observation approach. Data was taken in the MDR TB ward, samples were 100 documentation of pulmonary TB patients. Sampling technique was nonprobability sampling. Result. The goal of nursing diagnosis of ineffective airway clearance was airway clearance effectively again, the problem was resolved, the patient's airway returned to normal and coughing the patient returns to normal, etc. The goal of nursing diagnosis of ineffective breathing patterns was effective breathing patterns, ineffective breathing patterns resolved, etc. The outcome criteria of nursing diagnosis ineffective airway clearence was negative cough, normal respiratory rate, normal vital signs, negative sputum, shortness of breath, coughing resolved, comfortable patients, patients can demonstrate coughing effectively, sputum can come out, breath was relieved, sputum can come out, etc. The outcome criteria for nursing diagnosis ineffective breathing patterns are normal respiratory rate, normal vital signs, respiratory rate was 20 x/minute, it was not weakness, It was not nausea, etc. Recomendation. Nurses are advised to be given trainings, sosialisation, or workshops related to the goals and outcome criteria of nursing diagnoses, and are expected to use NANDA and NIC-NOC references.
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