使用基于网络的病例管理系统,为疗养院病人捕捉以功能为重点的关键护理问题、护理诊断和干预措施。

IF 1.4 4区 医学 Q3 NURSING
Su Jung Lee PhD, RN, Min Sun Park PhD, RN, Sung Ok Chang PhD, RN
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引用次数: 0

摘要

目的:本研究旨在利用基于网络的病例管理系统,为出现不同认知状况的患者确定关键功能护理问题、NANDA-I护理诊断以及与功能为中心的护理(FFC)相关的干预计划:本研究采用回顾性描述研究设计。研究小组在韩国忠清南道唐津的一家疗养院对病例管理系统进行培训后,从患者的系统记录中获取数据。共分析了 119 份住院病历:结果:确定了主要的身体、认知和社会功能问题、六个领域(健康促进、消除和交流、活动/休息、感知/认知、应对/压力耐受、安全/保护)的护理诊断以及干预计划:结论:已确定的跨学科护理人员的 FFC 病例管理信息将为根据患者的功能状态实施有效干预提供证据。还需要开展更多研究,以建立一个以跨学科护理人员功能管理为重点的先进病例管理系统大型临床数据库,从而为确定功能护理的优先次序提供支持。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Capturing key function-focused care problems, nursing diagnoses, and interventions for nursing home patients using a web-based case management system

Purpose

The aim of this study is to identify the key functional care problems, NANDA-I nursing diagnoses, and intervention plans related to function-focused care (FFC) using a web-based case management system for patients who present different cognitive status.

Methods

This study employed a retrospective descriptive research design. Data were obtained from system records on patients after the research team trained the case management system at a nursing home in Dangjin in South Chungcheong Province, South Korea. A total of 119 inpatient records were analyzed.

Results

The key physical, cognitive, and social functional problems, nursing diagnoses in six domains (health promotion, elimination and exchange, activity/rest, perception/cognition, coping/stress tolerance, and safety/protection), and intervention plans were identified.

Conclusion

The identified FFC case management information of interdisciplinary caregivers will provide evidence for the implementation of effective interventions according to a patient's functional status. Additional studies related to the establishment of a large clinical database of advanced case management systems focusing on interdisciplinary caregivers’ functional management are needed to support the prioritization of functional care.

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来源期刊
CiteScore
2.90
自引率
14.30%
发文量
47
审稿时长
>12 weeks
期刊介绍: The International Journal of Nursing Knowledge, the official journal of NANDA International, is a peer-reviewed publication for key professionals committed to discovering, understanding and disseminating nursing knowledge. The Journal aims to clarify the knowledge base of nursing and improve patient safety by developing and disseminating nursing diagnoses and standardized nursing languages, and promoting their clinical use. It seeks to encourage education in clinical reasoning, diagnosis, and assessment and ensure global consistency in conceptual languages. The International Journal of Nursing Knowledge is an essential information resource for healthcare professionals concerned with developing nursing knowledge and /or clinical applications of standardized nursing languages in nursing research, education, practice, and policy. The Journal accepts papers which contribute significantly to international nursing knowledge, including concept analyses, original and applied research, review articles and international and historical perspectives, and welcomes articles discussing clinical challenges and guidelines, education initiatives, and policy initiatives.
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