Applicability of nursing interventions classification for nursing records of Pediatric Respiratory Medicine Department
10.3760/cma.j.cn115682-20191120-04229
- VernacularTitle:护理措施分类用于儿童呼吸内科护理记录的适用性研究
- Author:
Yao WANG
1
;
Jiwen SUN
;
Lulu QIAN
;
Jinxian SHI
Author Information
1. 上海交通大学医学院附属上海儿童医学中心呼吸科 200127
- Keywords:
Child;
Nursing interventions classification;
Respiratory Medicine Department;
Nursing records;
Applicability
- From:
Chinese Journal of Modern Nursing
2020;26(26):3588-3594
- CountryChina
- Language:Chinese
-
Abstract:
Objective:To analyze the applicability of the 6th edition of nursing interventions classification in Pediatric Respiratory Medicine Department, so as to provide a basis for standardizing clinical nursing terms and promoting the clinical use of standardized nursing terminology.Methods:The research method of this research was mapping method. The electronic nursing records of Department of Respiratory Medicine in a ClassⅢGrade A children's specialty hospital from September 1 to November 30, 2018 were collected, including the nursing interventions recorded by free text and records of nursing interventions related to medical orders. The matching degree between electronic nursing records and standardized nursing interventions (the 6th edition of nursing interventions classification) was compared by concept consistency. Characteristics of standardized nursing interventions matched were analyzed by analyzing difficulty and time-consuming.Results:Totally, there were 84 standardized nursing interventions mapped from 3 258 independent electronic nursing statements, which involved 7 domains. Of the 3 258 statements, 3 183 (97.70%) were labelled as "perfect match", 55 (1.69%) as "partial match", and 20 (0.61%) as "not match at all". The average difficulty and time spent for the standardized nursing interventions were 1.76 and 2.02.Conclusions:Nursing interventions classification can be used to describe the daily behavior and activities of nurses in Pediatric Respiratory Medicine Department, and it can also solve the problem of standardization shown in nursing records. The results of this study can be used in the performance analysis of nursing staff with combination of difficulty and time-consuming empowerment in the future.
