Author Affiliations: Office of Hospital Information (Dr Sung, and Ms Kim) and Biomedical Research Institute (Dr Sung), Seoul National University Hospital, Seoul; and, Department of Nursing, Inha University, Incheon (Dr Jung), Republic of Korea.
Comput Inform Nurs. 2024 Feb 1;42(2):127-135. doi: 10.1097/CIN.0000000000001048.
This study explored nursing care topics for patients with the coronavirus disease 2019 admitted to the wards and intensive care units using International Classification for Nursing Practice-based nursing narratives. A total of 256630 nursing statements from 555 adult patients admitted from December 2019 to June 2022 were extracted from the clinical data warehouse. The International Classification for Nursing Practice concepts mapped to 301 unique nursing statements that accounted for the top 90% of all cumulative nursing narratives were used for analysis. The standardized number of nursing statements for each concept was calculated according to the types of nursing care and compared between the two groups. The most documented topics were related to infection; physical symptoms such as sputum, cough, dyspnea, and shivering; and vital signs including blood oxygen saturation and body temperature. Nurses in the intensive care units frequently documented concepts related to the directly monitored and assessed physical signs such as consciousness, pupil reflex, and skin integrity, whereas nurses in wards documented more concepts related to symptoms patients complained. This study showed that the International Classification for Nursing Practice-based nursing records can be used as source of information to identify nursing care for patients with coronavirus disease 19.
本研究使用基于国际护理实践分类的护理叙事探索了将 2019 年冠状病毒病患者收入病房和重症监护室的护理主题。从 2019 年 12 月至 2022 年 6 月期间从临床数据仓库中提取了 555 名成年患者的 256630 条护理记录。映射到 301 个独特护理记录的国际护理实践概念占所有累积护理记录的前 90%，用于分析。根据护理类型计算了每个概念的标准化护理记录数量，并在两组之间进行了比较。记录最多的主题与感染、痰、咳嗽、呼吸困难和寒战等身体症状以及血氧饱和度和体温等生命体征有关。重症监护病房的护士经常记录与意识、瞳孔反射和皮肤完整性等直接监测和评估的身体体征有关的概念，而病房的护士则记录了更多与患者抱怨的症状有关的概念。本研究表明，基于国际护理实践分类的护理记录可作为识别冠状病毒病患者护理的信息来源。
