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研究生:江志偉
研究生(外文):Chin-Wei Chiang
論文名稱:護理過程支援資訊系統-入院評估表單
論文名稱(外文):Supporting Nursing Process with Nursing Information Systems–based on Admission Assessment
指導教授:劉建財劉建財引用關係
指導教授(外文):Chien-tsai Liu
學位類別:碩士
校院名稱:臺北醫學大學
系所名稱:醫學資訊研究所
學門:醫藥衛生學門
學類:醫學技術及檢驗學類
論文種類:學術論文
論文出版年:2008
畢業學年度:96
語文別:中文
論文頁數:135
中文關鍵詞:護理計畫護理診斷護理過程入院護理評估
外文關鍵詞:Care PlanNursing DiagnosisNursing ProcessAdmission Assessment
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臨床上護理人員在制定護理計劃時,需要參照許多的書籍,包括護理診斷、護理結果、護理措施等書,而2007-2008年時北美護理診斷協會(NANDA)的護理診斷已發展到有187個項目,護理敏感之病患結果分類(NOC)有330個,護理措施分類(NIC)也有542個,如此多的項目跟分類,要能夠正確的使用,將有其難度。本研究主要目的為發展護理過程輔助系統,以期減少護理人員文書作業,提高記錄的正確性和時效性,以及增加病患直接護理時間。依照護理臨床實務藉由護理人員的臨床評估,由入院評估表單(結合三家醫學中心及護理診斷手冊)進入護理診斷及護理診斷之定義特徵,再連結至護理敏感之病患結果分類與護理措施分類,系統用結構化查詢語言(Structured Query Language, SQL)資料庫,以動態伺服器網頁(Active Server Pages, ASP)呈現,使用者根據系統輔助判斷與決定之後完成病人之臨床照護計畫。將臨床評估填進入院評估表單內後,本研究所設計的系統會將所填項目轉換至定義性特徵,並將定義性特徵所占的百分比及數量顯示提供參考,護理人員依照所建議的定義性特徵決定護理診斷,配合臨床的經驗與判斷,為該病人建立詳細的護理計劃,護理人員可即隨時列印該病人護理計劃,實行護理措施。在訂立護理計畫的整個過程中,記錄所有選項,在未來將提供電腦建議護理診斷準確度的參考。而在輸出資訊方面除了將護理計畫整理並列表外,系統所採用的是國際通用編碼,只須將所實施的護理措施做一轉換,輸出相對的編碼,就能夠完成。本次研究雖然以入院護理評估表單為主,但其模式可以延伸至其他不同科別之護理評估表單,只要該科別護理評估表單,將其個別詳細項目與定義性特徵連結,如此便可藉由定義性特徵與護理診斷資料庫連結,同樣可以做出建議性診斷與決策,讓護理人員作為臨床決策的參考。另外,電子化的護理照護也可藉由個案模擬過程,提供新進人員及護生,一個數位學習的管道,將有助於護理教育的發展與應用。
The nursing staff needs to consult a lot of books while making a health care plan, including nursing diagnosis, nursing-sensitive patient outcomes classification (NOC), nursing interventions classification (NIC) and so on. NANDA(North American Nursing Diagnosis Association)have published 187 nursing diagnoses in year 2007-2008, The Center for Nursing Classification & Clinical Effectiveness at the College of Nursing, The University of Iowa have published 330 NOC, and 542 NIC. It is very difficult to link them together at point of care. The purposes of this research are to develop a decision support system to help decision making in nursing diagnosis, nursing outcomes classification, nursing intervention and nursing documentation. The system can then be expected to reduce nursing staff''s workload in documentation, to improve exactness and timeliness in writing nursing records, and to increase time for patient’ care. As a part of the admission assessment the primary nurse determines the nursing orders based on the signs, symptoms, diagnoses, and expected outcomes, then decides the interventions of the care plan. The admission assessment data are also input to the system, which map them into the corresponding defining characteristics, and produces a list of suggested nursing diagnoses. Each suggested diagnose is associated with the percentage of matched defining characteristics for that diagnose. A nurse can select the appropriate one(s) or add new one(s) if they are not in the suggestion list. After, choosing the nursing diagnoses, the system can link the diagnoses to the expected patient outcomes and interventions that make up the health care plan. With the help of the system, nurses can use their expertise through critical thinking to make nursing diagnoses and care plans. The system has been designed based on admission assessment data, which based on admission assessment data, which can easily be extended to other forms of nursing assessment. The computerized nursing care plans can be used to create study cases for e-learning in support of nursing education.
目錄
第一章 緒論
1.1 背景介紹 1
1.2 研究動機 1
1.3 研究目的 5
第二章 文獻查證
2.1 護理過程發展史 7
2.2 護理過程內涵與架構 8
2.3 入院護理評估表 14
2.4 護理診斷 15
2.5 護理實務分類系統 22
2.6 護理診斷、護理成果與護理措施之連結應用 27
2.7 護理資訊化系統 29
第三章 研究材料與方法
3.1 病患的入院評估 38
3.2 入院評估表單 39
3.3 臨床現象 44
3.4 定義性特徵 45
3.5 護理診斷、護理成果與護理措施之連結 48
3.6 護理計劃 53
3.7 總述 54
第四章 結果
4.1 輔助計畫流程結果 55
4.2 硬體架構 57
4.3 軟體架構 58
第五章 討論
5.1 護理診斷的確立與護理計劃的制定 61
5.2 護理資料庫的擴充與更新 62
5.3 護理計畫與其他編碼系統的輸出與連結 62
5.4 電子化的照護計畫 63
第六章 結論與建議
6.1 資訊與護理的結合 64
6.2 教學輔助 64
6.3 未來 65
參考資料
中文文獻 67
英文文獻 67
電子資料 69
附錄
附錄一 Nursing Diagnosis 71
附錄二 Nursing Outcomes Classification 77
附錄三 Nursing Interventions Classification 98

表目錄
表一、入院評估表單 ...................................................................... 41
表二、由臨床現象建議可能相關之護理診斷範例.........................................44
表三、一般性評估,直接連結至定義性特徵,再建議可能相關之護理診斷
.................................................................................................................47
表四、衍生之護理診斷,帶出同護理診斷之其他定義性特徵 ................ 48
表五、 linkage of NANDA、 NIC and NOC suggest........................... 51
表六、 將NANDA、NIC 及 NOC 資料連結以後轉成電子資料庫之護理診
斷分類項目範例 ................................................................... 51
表七、將NANDA、NIC 及 NOC 資料連結以後轉成電子資料庫之NOC 範
例 ...................................................................................... 52
表八、將NANDA、NIC 及 NOC 資料連結以後轉成電子資料庫之NIC 範
例 ...................................................................................... 52

圖目錄
圖一、護理計畫製作輔助系統之流程架構.......................................... 38
圖二、護理計畫製作輔助系統電子資料庫中之護理診斷連結依據.............50
圖三、計劃制定方式範例.................................................................................53
圖四、護理實務的定義特徵、護理過程及護理實務標準之間的關係 ...... 54
圖五、系統實作一.......................................................................... 55
圖六、系統實作二.......................................................................... 56
圖七、系統實作三.......................................................................... 56
圖八、系統實作四.......................................................................... 57
圖九、系統實作五.......................................................................... 57
圖十、系統作業流程 ...................................................................... 60
中文文獻
于博芮、鄭綺,新護理診斷手冊•台北:華杏,1997。
方妙君等,護理過程•台北:華杏,2004。
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李薇莉等,護理診斷手冊- 護理計畫之指引•台北,合記圖書,2006。
施威銘研究室,Microsoft SQL Server 2005 設計實務,台北市:旗標,2006。
黃興進,醫療資訊管理系統研究議題之探討•資訊管理學報,2002;(S),101-116。
董大偉,《ASP.NET 2.0深度剖析範例集》,台北:博碩文化,2006。
張慧朗等,醫學資訊管理學•台北:華杏,2007。
蘇喜、蕭淑珍、黃璉華,護理電腦化•台北:華杏,1995。


英文文獻
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Bates, D.W., Ebell, M., Gotlieb, E., Zapp, j., & Mullins, H. C. A proposal for electronic medical records in U.S. primary care. Journal of American Medical Informatics Association, 2003. 10(1), 1-10.
Brooks, B. A., & Massanari, K. Implementation of NANDA nursing diagnoses online. North American Nursing Diagnosis Association. Computers in Nursing 1998; 16(6), 320-326.
Devine EC, Werley HH. Test of the nursing minimum data set: availability of data and reliability. Res Nurs Health. 1988;Apr;11(2):97–104.
Drazen, E., Metzger, J., Ritter, J., & Schneider, M. Patient care information systems: Successful design and implementation. New York: Springer-Verlag 1995.
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Lowa Intervention Project. Nursing Interventions Classification (NIC). St. Louis: Mosby 1992.
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電子資料
International Classification for Nursing Practice (ICNP). Taipei medical university. Available at: http:// www.icn.ch/ Accessed may 1, 2008.
Nursing Diagnoses: Definitions and Classification, 2007-2008. Taipei medical university. Available at: http://www.nanda.org/ Accessed may 1, 2008.
Nursing Interventions Classification (NIC). Taipei medical university. Available at: http://www.nursing.uiowa.edu/ Accessed may 1, 2008.
Nursing-Sensitive Patient Outcomes Classification (NOC). Taipei medical university. Available at: http://www.nursing.uiowa.edu/ Accessed may 1, 2008.
The Clinical Care Classification System (CCCS). Taipei medical university. Available at: http:// www.sabacare.com/ Accessed may 1, 2008.
The Omaha System. Taipei medical university. Available at: http://www.omahasystem.org/ Accessed may 1, 2008.
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