Bowles K H
School of Nursing, University of Pennsylvania, Philadelphia, USA.
J Cardiovasc Nurs. 2000 Apr;14(3):29-41. doi: 10.1097/00005082-200004000-00006.
Standardization and computerization of medical documentation has provided a method to describe patient care by naming and linking patients' needs with nursing interventions. This study used a standardized nursing classification system to describe the types and frequency of problems experienced by elders hospitalized and discharged to home and the interventions used by staff nurses and advanced practice nurses (APNs) as they provided acute care and discharge planning for these cardiac patients. The patients' hospital records and the APN logs were content analyzed and then coded using the Problem Classification Scheme and Intervention Scheme of the Omaha System. Patients experienced an average of 8.6 problems that required a total of 7,000 interventions in all four Omaha System intervention categories. The results provided a description of the most frequent problems experienced by the patients linked with the most common nursing interventions. The nature, complexity, and prevalence of patient problems and the importance of communication across settings are evident. In addition, the study findings increase understanding of the contribution of nurses to the care of hospitalized elders as they make the transition from hospital to home.
医疗文档的标准化和计算机化提供了一种方法，通过命名患者需求并将其与护理干预措施相联系来描述患者护理情况。本研究使用标准化护理分类系统，描述了住院后出院回家的老年人所经历问题的类型和频率，以及注册护士和高级执业护士在为这些心脏病患者提供急性护理和出院计划时所采用的干预措施。对患者的医院记录和高级执业护士日志进行了内容分析，然后使用奥马哈系统的问题分类方案和干预方案进行编码。患者平均经历了8.6个问题，在奥马哈系统的所有四个干预类别中总共需要7000次干预。研究结果描述了与最常见护理干预措施相关的患者最常出现的问题。患者问题的性质、复杂性和普遍性以及跨环境沟通的重要性显而易见。此外，研究结果加深了人们对护士在住院老年人从医院过渡到家庭过程中所提供护理的贡献的理解。
