制定围手术期护理干预记录的术语。

Developing terminology for documenting perioperative nursing interventions.

作者信息

Junttila Kristiina, Salanterä Sanna, Hupli Maija

机构信息

Helsinki University Central Hospital/Jorvi Hospital, Turuntie 150, FIN-02740 Espoo, Finland.

出版信息

Int J Med Inform. 2005 Jul;74(6):461-71. doi: 10.1016/j.ijmedinf.2005.04.001.

DOI:10.1016/j.ijmedinf.2005.04.001

PMID:15893502

Abstract

OBJECTIVE

To develop terminology for documenting perioperative nursing interventions.

METHOD

Nursing documentation of 250 patients was explored by content analysis. The study was conducted to validate further the Perioperative Nursing Data Set (PNDS) in Finland. The data included 3442 terms that were clustered into 104 nursing interventions. A Delphi-panel (N=5) evaluated the relevance of each term on a scale from 1 to 4. The structure of each nursing intervention was checked to meet the minimum requirements of the ISO reference terminology model for nursing action concepts. Finally, the nursing interventions were compared with the original PNDS-interventions.

RESULTS

The Delphi-panel accepted 98 nursing interventions with Content Validity Index from 0.88 to 1.0. Of the 133 nursing interventions in the PNDS, 60% (n=80) were covered by nursing interventions identified in this study. A notable portion of the nursing interventions related to preventive aspects of perioperative care and the patients' coping with perioperative experience.

CONCLUSION

The findings supported the need for cross-cultural validation of a nursing language prior to clinical implementation. The ISO reference terminology model is recommended as framework in constructing concepts for nursing interventions in a regular form.

摘要

目的

制定围手术期护理干预记录的术语。

方法

通过内容分析法对250例患者的护理记录进行探究。该研究旨在进一步验证芬兰的围手术期护理数据集（PNDS）。数据包含3442个术语，这些术语被聚类为104项护理干预。一个德尔菲小组（N = 5）以1至4的量表评估每个术语的相关性。检查每项护理干预的结构，以符合护理行动概念的ISO参考术语模型的最低要求。最后，将这些护理干预与原始的PNDS干预进行比较。