护理个案报告中护理问题在护理分类系统中的术语映射分析  

Analysis on terminology mapping of nursing problems in case report according to nursing classification system

作　　者：饶堃 彭刚艺 刘雪琴 曾迎春[4] 张茹欣 钟一岳 黄添容 Rao Kun;Peng Gang yi;Liu Xueqin;Zeng Yingchun;Zhang Ruxin;Zhong Yiyue;Huang Tianrong(Nutritional Department,Guangzhou Eighth People′s Hospital,Guangzhou 510060,China)

机构地区：[1]广州市第八人民医院营养科,广东广州510060 [2]广东省卫生健康委员会医政处 [3]南方医科大学护理学院 [4]广州医科大学附属第三医院护理教研室 [5]中国医学科学院阜外医院深圳医院CCU [6]广东医科大学附属医院介入室 [7]南方医科大学第三附属医院神经内科

出　　处：《护理学杂志》2020年第2期26-30,共5页Journal of Nursing Science

摘　　要：目的了解护理个案报告中的护理问题与三大护理术语分类系统呈现交集的现况及国内护士对护理诊断的认知,为建立我国本土化护理术语系统提供参考。方法选取44份护理个案报告中的326条护理问题,分别按疾病、症状、功能、健康形态、风险5类映射到国际北美护理诊断(NANDA-I)、奥马哈系统、临床照护分类系统(CCC),并对映射结果进行比较。结果护理问题在三大护理分类系统的分布差异有统计学意义(P<0.01);奥马哈系统和CCC在疾病分类中更有优势,NANDA-I和CCC在健康形态分类中较奥马哈系统有显著优势(P<0.05,P<0.01),除疾病分类外,NANDA-I和CCC在其他分类中表现出较好的一致性(Kappa>0.61)。风险类问题存在39.4%的映射缺失。结论护理个案中的护理问题在三大护理术语分类系统中映射的吻合程度低,尤其是疾病与风险为焦点的护理问题。症状、功能、健康形态此类问题则在NANDA-I和CCC的映射结果存在共性。需结合医护合作模式,针对三大护理分类系统各自的优点建立本土化护理术语。Objective To observe the intersection of nursing problems expressed by Chinese nurses in nursing case and the three nursing terminology classification system,to understand Chinese nurses′cognition of nursing diagnosis,and to provide reference for establishing localized nursing terminology system in China.Methods Totally 326 nursing problems in 44 nursing case reports were selected and mapped to NANDA-I,Omaha System and Clinical Caring Classification(CCC)system according to disease,symptom,function,health pattern and risk 5 categories,then the mapping results were compared.Results The distribution of nursing problems in the 3 nursing classification systems was different(P<0.01).Omaha System and CCC had more advantages in the classification of diseases,NANDA-I and CCC had more significant advantages in the classification of health pattern forms when compared with Omaha System(P<0.05,P<0.01).NANDA-I and CCC showed good consistency in other classifications except disease(Kappa>0.61).Totally 39.4%missing mapping existed in risk problems.Conclusion The coincidence of expressed nursing problems in case reports is low when mapped with the three terminology classification systems,especially the disease and risk focused nursing problems.The nursing problems of symptom,function and health patterns have something in common in the mapping result of NANDA-I and CCC.It is necessary to establish localized nursing terminology according to the advantage of the 3 major classification systems and combining with physican-nurse cooperation model.

关 键 词：护理个案 护理问题 国际北美护理诊断 奥马哈系统 临床照护分类系统 标准化护理术语 护理诊断 术语映射 

分 类 号：R471[医药卫生—护理学] C931.4[医药卫生—临床医学]