Brooks B A, Massanari K
Our Lady of the Resurrection Medical Center, Chicago, Illinois, USA.
Comput Nurs. 1998 Nov-Dec;16(6):320-6.
The authors describe the online implementation of the standardized nursing language of the North American Nursing Diagnosis Association (NANDA) nursing diagnoses at one 250-bed community hospital located in Chicago. A brief description of NANDA nursing diagnoses is provided along with a discussion of issues regarding implementation of these nursing diagnoses in a clinical information system. This system did not support online documentation of patient problems, therefore the challenge was to add documentation of patient problems to the system's software. This article focuses on the design and implementation of the nursing diagnoses computer screens, rather than focusing on the two problems we encountered during implementation--appropriate use of nursing diagnoses and the fit of nursing diagnoses with nursing interventions. Yet, the lessons learned in designing and implementing NANDA nursing diagnoses online may help others.
作者描述了位于芝加哥的一家拥有250张床位的社区医院对北美护理诊断协会（NANDA）护理诊断标准语言的在线实施情况。文中简要介绍了NANDA护理诊断，并讨论了在临床信息系统中实施这些护理诊断的相关问题。该系统不支持患者问题的在线记录，因此面临的挑战是在系统软件中添加患者问题记录功能。本文重点关注护理诊断计算机屏幕的设计与实施，而非实施过程中遇到的两个问题——护理诊断的恰当使用以及护理诊断与护理干预的适配性。然而，在线设计和实施NANDA护理诊断所吸取的经验教训可能会对他人有所帮助。
