以兒科加護病房護理表單為基礎之護理診斷決策輔助系統
中文摘要
論文摘要
論文名稱：以兒科加護病房護理表單為基礎之護理診斷決策輔助系統
研究所名稱：臺北醫學大學醫學資訊研究所
研究生姓名：鄭詩慈
畢業時間：九十六學年度 第二學期
指導教授：劉建財
國內醫療院所自民國 74 年開始推行 NANDA 護理診斷，藉此將護理過程的各個環節整合至臨床病患照顧工作中，以提升護理品質；目前各 家醫院所導入的護理診斷資訊系統，多數僅將護理診斷內容及格式標準化，主要目的是取代人工書寫作業，但護理問題相關資料之收集與 整合仍需以人工方式實現，護理診斷的確立也是基於護理人員自身的經驗判斷，較缺乏護理診斷推論的過程及精神。因此，本研究期望能 利用臨床護理表單提供的表單欄位內容，找出相對應的護理診斷定義性特徵及導因，藉由系統自動轉換及對應機制，進行病患表單資料的 自動判斷及歸納，推論出與病患現況相符之定義性特徵，產生護理診斷建議清單。
本研究對象為某醫學中心兒童加護病房，收集該單位三張紙本臨床護理表單，及二十八個兒科常用護理診斷及定義性特徵。首先依據表單 欄位特性將欄位重整及編碼，接著擴展為表單欄位之臨床判斷，與意義相符之定義性特徵和導因進行人工對應，形成護理診斷推論知識庫
，最後以該知識庫為核心，建立虛擬之護理診斷決策輔助系統。系統評估則輸入 35 位兒童加護病房病患之真實數據，經系統進行分析及推 論，得到各病患之護理診斷建議清單，並請護理專家檢視後以五分法進行護理診斷適當性評分，另列出各病患需以手動方式加入之護理診 斷，計算自動推論與手動加入之護理診斷的比例。
本護理診斷決策輔助系統之功能包括 : (1) 對病患表單欄位資料進行分析並提出可成立之臨床判斷； (2) 依據成立之臨床判斷列出相對應之 定義性特徵及護理診斷； (3) 利用系統條件限制產生護理診斷建議清單；且使用者可彈性調整建議清單內容並決定是否接受。系統評估由三 位護理專家進行，護理診斷適當性評分，同意以上得分的平均有 91% ，不同意以下得分的平均有 4% ；而系統經由自動推論可得到 95% 的 護理診斷， 5% 須透過手動方式加選。因此，本研究之護理診斷決策輔助系統利用護理診斷推論知識庫可以推論出護理診斷建議清單，更可 以提供護理診斷成立的確切證據。
關鍵字：病患安全 顯影劑誘發腎病變 決策支援 醫令系統 影像檢查 腎功能不全
A Nursing Diagnosis Decision Support System Based On Pediatric Intensive Care Unit Nursing Forms
英文摘要
Since 1985 ， Taiwan’s hospitals started to carry out the NANDA nursing diagnosis, and linked the diagnosis into the workfl ow of nursing care to promote the quality of care. However, most hospitals implementing their nursing information systems o nly standardized forms and formats of nursing diagnoses for substitution of manually hand-writing work. They collect data m anually, and make nursing diagnosis based on their own experience, not based on the deduction rules as those in the NANDA specification. Therefore, the goal of this research is to produce a nursing diagnose using the field data in nursing forms used to collect data routinely by clinical nurses. In the approach presented here we map nursing form fields into the corresponding nur sing diagnosis definition characteristics, and then map the definition characteristics and other patient present conditions to a s uggestion list of plausible nursing diagnoses for user selection.
In this thesis we uses a pediatric intensive care unit in a medical center as a base for field research. We collect three clinical nu rsing forms and 28 nursing diagnoses and their definition characteristics commonly used in the pediatric department. After for m item rallying and code, extends the form item becomes the clinical judgment, then manual corresponds the clinical judgmen t and the definition characteristic that have the same significance. These correspondences will form the nursing diagnosis deci sion knowledge base; finally, take it as the core to implementing the nursing diagnosis decision support system. The system e valuation inputs 35 case clinical nursing form data, and analysis those data by the system, to obtain nursing diagnosis suggesti on list for each case; next, the nursing expert evaluate suggestion list to be whether suitable by five-level Likert scale, and rec ords the nursing diagnosis by the manual way for computation automatic deduction to manual joins proportion.
There support system was composed three functions: 1. Transforms clinical form data become the clinical judgment; 2. lists th e definition characteristic and the nursing diagnosis which corresponds with the clinical judgment; 3. proposes the nursing dia gnosis suggestion list. The user can adjust suggestion list and decided whether to accept. The system evaluation by three nursi ng experts; suggestion list suitability was 91% above agrees, 4% under disagree; the system can obtain 95% nursing diagnosis by way of the automatic deduction, 5% by the manual way. Therefore, this system using the nursing diagnosis decision knowl edge base, can effectively assist nursing diagnosis decision-making, and also provide the evidence for the patient’s nursing dia gnosis.
