Serrano Sastre R, Saracíbar Rázquin M I, Carrascal Garchitorena E, Tina Majuelo P, Narvaiza Solís M J, Sanz Izco M, Díaz Navarlaz M T
Clínica Universitaria de la Universidad de Navarra.
Rev Enferm. 1997 Jul-Aug;20(227-8):23-31.
The objectives of this study were: A) to assemble a Standard Care Plan Guide taken from both nursing care records as well as data from a bibliography review; B) to know the number of nursing interventions and evaluate their suitability according to the stated nursing diagnosis. These results can then be compared before and after using the Standard Care Plan Guide. An analysis of 1827 nursing care records was performed. The first phase, after studying 1255 records, consisted of standardizing the care to correspond with 36 nursing diagnoses previously selected from the NANDA taxonomy. The second phase saw the standard care practice incorporated by the nursing staff. And finally, a comparison was made of the results between phase one and three (before and after the incorporation of the Standard Care Plan Guide.) The number of nursing interventions notably increased, jumping from 3263 in the first phase up to 4271 in the third. The average nursing action per patient rose from 3.03 to 9.09. Also, the diagnostic categories increased, going from 930 in the first phase up to 1624 in the third. The average number of correctly stated diagnoses per patient climbed from 1.56 to 2.78. The authors state that better nursing care and attention to the patient can occur if the nurses are given the conceptual instruments and training that will facilitate their daily tasks.
A)汇编一份标准护理计划指南,该指南取自护理记录以及文献综述数据;B)了解护理干预的数量,并根据所述护理诊断评估其适用性。然后可以在使用标准护理计划指南前后对这些结果进行比较。对1827份护理记录进行了分析。第一阶段,在研究了1255份记录后,包括将护理标准化,以符合先前从北美护理诊断协会(NANDA)分类法中选出的36项护理诊断。第二阶段是护理人员采用标准护理实践。最后,对第一阶段和第三阶段(采用标准护理计划指南前后)的结果进行了比较。护理干预的数量显著增加,从第一阶段的3263项跃升至第三阶段的4271项。每位患者的平均护理行动从3.03次增加到9.09次。此外,诊断类别也有所增加,从第一阶段的930项增加到第三阶段的1624项。每位患者正确陈述的诊断平均数量从1.56项攀升至2.78项。作者指出,如果护士获得有助于其日常工作的概念工具和培训,就能提供更好的护理并给予患者更多关注。