Ríos H, Delaney C, Kruckeberg T, Chung Y H, Mehmert P A
College of Nursing, University of Iowa, Iowa City 52246.
J Prof Nurs. 1991 Sep-Oct;7(5):293-9. doi: 10.1016/8755-7223(91)90116-3.
As the use of nursing diagnoses in clinical practice increases, systematic research is necessary to appropriately validate them. Validity studies could be expedited by the use of information technology and computerized clinical data bases. The purpose of the following descriptive study was to validate the defining characteristics (risk factors for potential diagnoses) of the four nursing diagnoses related to alterations in fluid volume proposed by the North American Nursing Diagnosis Association using a nursing minimum data set (NMDS) collected from a computerized nursing data base. A sensitivity measure, the proportion of subjects with specific defining characteristics for a given diagnosis among the total number of subjects with the respective diagnosis, was used to estimate validity. The study was conducted in a 265-bed, mid-western, community hospital in which computerized nursing diagnosis care planning is used. The elements of the NMDS and defining characteristics were collected from a systematic sample (N = 191). The sample consisted of a proportion of about half of computerized discharge patient care plan summaries from each of the four diagnostic labels related to alteration in fluid volume obtained from medical records during the 1987 calendar year. Discharge patient care plan summaries contained at least one of four nursing diagnoses related to alteration in fluid volume. The results show the existence of individual defining characteristics as well as combinations of defining characteristics meeting validation criteria for each diagnostic label. Never-documented defining characteristics also were identified.
随着护理诊断在临床实践中的应用不断增加，有必要进行系统研究以对其进行适当验证。利用信息技术和计算机化临床数据库可加快有效性研究。以下描述性研究的目的是使用从计算机化护理数据库收集的护理最小数据集（NMDS），验证北美护理诊断协会提出的与液体量改变相关的四种护理诊断的定义特征（潜在诊断的危险因素）。使用一种敏感性测量方法，即给定诊断的具有特定定义特征的受试者在相应诊断的受试者总数中所占的比例，来估计有效性。该研究在一家拥有265张床位的中西部社区医院进行，该医院采用计算机化护理诊断护理计划。从一个系统样本（N = 191）中收集了NMDS的要素和定义特征。该样本包括1987历年从病历中获取的与液体量改变相关的四个诊断标签中每个标签的约一半计算机化出院患者护理计划摘要。出院患者护理计划摘要包含与液体量改变相关的四个护理诊断中的至少一个。结果显示了个体定义特征的存在以及符合每个诊断标签验证标准的定义特征组合。还识别出从未记录的定义特征。
