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急诊科计算机化护理流程的构建方法

Structuring methodology of the Computerized Nursing Process in Emergency Care Units.

作者信息

Paese Fernanda, Sasso Grace Teresinha Marcon Dal, Colla Gabriela Winter

机构信息

Universidade Federal de Santa Catarina, Florianópolis, Santa Catarina, Brazil.

出版信息

Rev Bras Enferm. 2018 May;71(3):1079-1084. doi: 10.1590/0034-7167-2016-0619.

Abstract

OBJECTIVE

To structure the Computerized Nursing Process using the International Classification for Nursing Practice (ICNP®) version 2.0 to emergency care units in a computerized structure.

METHOD

This is a methodological and technological research that followed the stages: (1) establishment of the development team and resources; (2) adequacy of clinical situations, diagnoses and nursing interventions for the emergency area; (3) association of diagnoses and interventions based on ICNP®; (4) organization and codification of clinical evaluation, diagnoses and nursing interventions; (5) transfer of data to the a computerized platform.

RESULTS

Readjustment and construction of 1,445 possibilities of clinical evaluations associated with 961 different diagnoses and their corresponding interventions to the most frequent situations in emergency services.

CONCLUSION

ICNP® has a strong and solid form for the development of the computerized nursing process able to support nurses in safe decision-making to improve the quality of health care.

摘要

目的

使用国际护理实践分类法(ICNP®)第2.0版构建计算机化护理流程,应用于急诊护理单元的计算机化架构。

方法

这是一项方法学和技术研究,遵循以下阶段:(1)组建开发团队并配备资源;(2)使临床情况、诊断和护理干预适用于急诊领域;(3)基于ICNP®关联诊断和干预措施;(4)组织和编码临床评估、诊断及护理干预措施;(5)将数据传输至计算机化平台。

结果

针对急诊服务中最常见的情况,重新调整并构建了1445种临床评估可能性,关联961种不同诊断及其相应干预措施。

结论

ICNP®为计算机化护理流程的开发提供了强大而坚实的形式,能够支持护士进行安全决策,以提高医疗保健质量。

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