Gomez de Segura Navarro Carlota, Esain Larrambe Ainhoa, Tina Majuelo Pilar, Guembe Ibáñez Irene, Fernández Perea Laura, Narvaiza Solís M Jesús
Unidad Médica, Clínica Universitaria, Universidad de Navarra.
Rev Enferm. 2006 Jul-Aug;29(7-8):21-6.
(a) to determine the effectiveness of a nursing document which integrates nursing diagnoses, nursing treatments/actions (NIC), and results (NOC); (b) to verify the application of the aforementioned document in a hospitalization unit.
A descriptive, transversal and observational study.
Nursing documents (NANDA, NIC and NOC taxonomies). PHASES: 1st: analysis of the content in the nursing documentation for 23 pneumonic patients: Selection of nursing diagnoses and the most frequent interdependent problems. 2nd: Selection of results and nursing treatment/actions. 3rd: Elaboration of the document and a description of the Likert scales to define the state of the indicators for each result. 4th: A pilot study of the document applied to 12 patients.
the application of the document permits one to identify the real status of a patient; to establish specific objectives; to improve the recording of data; to observe the effectiveness of treatment; to include educational activities; to give greater continuity and quality to a treatment plan.
(a) 确定一份整合护理诊断、护理措施/行动（护理干预分类系统）和结果（护理结局分类系统）的护理文件的有效性；(b) 验证上述文件在一个住院科室的应用情况。
一项描述性、横断面观察性研究。
护理文件（北美护理诊断协会、护理干预分类系统和护理结局分类系统分类法）。阶段：第1阶段：对23例肺炎患者的护理记录内容进行分析：选择护理诊断和最常见的相互关联问题。第2阶段：选择结果和护理措施/行动。第3阶段：编写文件并描述李克特量表以界定每个结果指标的状态。第4阶段：对应用于12例患者的文件进行预试验。
该文件的应用能够让人识别患者的实际状况；确立具体目标；改进数据记录；观察治疗效果；纳入教育活动；使治疗计划更具连贯性和质量。
