Liljamo Pia, Kinnunen Ulla-Mari
Oulu University Hospital, Northern Ostrobothnia District, Oulu, Finland.
University of Eastern Finland, Kuopio, Finland.
Stud Health Technol Inform. 2020 Nov 23;275:122-126. doi: 10.3233/SHTI200707.
Pain management, assessment and documentation is a crucial part of patient care. However, several studies show flaws in pain management processes. Documentation is not unified or even sufficient. The aim of this study was to describe how patient pain management has been recorded using the nursing diagnoses and nursing interventions of a standardized terminology, the Finnish Care Classification, (FinCC), and how that terminology should be further developed. The research data consisted of the daily nursing documentation notes of patient care episodes (n=806) during inpatient days (n=2564) at several specialty units (n=9). The documentation of pain management was found inadequate and insufficient. The results support the development of a new component, Pain management, and its attendant categories in the new version, FinCC 4.0, to help nurses document pain management in their daily work.
疼痛管理、评估及记录是患者护理的关键部分。然而，多项研究表明疼痛管理流程存在缺陷。记录不统一甚至不充分。本研究的目的是描述如何使用标准化术语芬兰护理分类法（FinCC）的护理诊断和护理干预措施来记录患者的疼痛管理，以及该术语应如何进一步发展。研究数据包括几个专科病房（n = 9）住院日（n = 2564）期间患者护理事件的每日护理记录（n = 806）。结果发现疼痛管理的记录不充分且不足。这些结果支持在新版本的FinCC 4.0中开发一个新的组成部分“疼痛管理”及其相关类别，以帮助护士在日常工作中记录疼痛管理情况。
