McLean Patricia A
CUNY Graduate Center, New York, New York, USA.
Int J Nurs Terminol Classif. 2011 Jul-Sep;22(3):142-6. doi: 10.1111/j.1744-618X.2011.01187.x.
The purpose of this case study is to illustrate the nursing process by incorporating the standardized nursing languages of NANDA International, the Nursing Interventions Classification, and the Nursing Outcomes Classification to assist an older adult with a history of falls.
The data sources were the author's clinical nursing practice and research-based evidence related to falls of older adults.
The data were synthesized by using clinical reasoning to select the best possible nursing diagnoses, interventions, and patient outcomes.
To provide a framework for nurses to achieve positive patient outcomes, standardized nursing languages should be incorporated into patients' clinical nursing databases.
In determining factors that relate to falls, nurses need to obtain baseline data, set goals with patients, and identify milestones, while encouraging patients to be active participants in plans of care.
本案例研究的目的是通过整合国际护理诊断协会（NANDA）、护理干预分类系统（NIC）和护理结局分类系统（NOC）的标准化护理语言，来说明护理程序，以帮助有跌倒史的老年人。
数据来源为作者的临床护理实践以及与老年人跌倒相关的循证研究。
通过临床推理来综合数据，以选择最佳的护理诊断、干预措施和患者结局。
为给护士提供一个实现积极患者结局的框架，应将标准化护理语言纳入患者的临床护理数据库。
在确定与跌倒相关的因素时，护士需要获取基线数据，与患者设定目标并确定里程碑，同时鼓励患者积极参与护理计划。
