2型糖尿病住院患者核心护理标准化语言的构建

doi:10.3761/j.issn.1672-9234.2024.07.019

摘要/Abstract

摘要：

目的构建2型糖尿病住院患者核心护理标准化语言，为规范临床护理记录提供参考。方法聚焦2型糖尿病住院患者的护理，通过文献检索、回顾医院护理记录及专家咨询确定2型糖尿病住院患者核心护理诊断，通过“国际北美护理诊断协会分类（North American Nursing Diagnosis Association International，NANDA-Ⅰ）、护理措施分类（Nursing Interventions Classification，NIC）、护理结局分类（Nursing Outcomes Classification，NOC）”（简称NNN链接）初步筛选核心护理诊断所匹配的核心护理结局、护理指标及核心护理措施、护理活动，邀请21名专家进行2轮函询进行修订完善，最终形成2型糖尿病住院患者核心护理标准化语言。结果 2型糖尿病住院患者核心护理标准化语言包括6项护理诊断、11项护理结局（52项护理指标）、15项护理措施（126项护理活动）。结论本研究构建的2型糖尿病住院患者核心护理标准化语言符合我国国情、文化背景、语言理解及临床实践，具有专业性、科学性，有利于实现护理语言的标准化，提升糖尿病专科护理质量。

关键词: 糖尿病, 2型, 护理诊断, 护理结局分类, 护理措施分类

Abstract:

Objective To construct standardized nursing language for hospitalized patients with type 2 diabetes，to provide references for the standardizing of clinical nursing records，and promote the development of clinical nursing information system database. Methods Focusing on the nursing care for hospitalized patients with type 2 diabetes，the core nursing diagnosis of hospitalized patients with type 2 diabetes was determined through literature retrieval，review of hospital nursing records and expert consultation. NANDA-Ⅰ，Nursing Interventions Classi-fication（NIC），Nursing Outcomes Classification（NOC）（referred to as NNN link for short） were initially screened for the core nursing outcomes，nursing indicators，core nursing measures and nursing activities matched by the core nursing diagnosis. After that，21 experts were invited to conduct two rounds of correspondence for revision and improvement. Finally，the standardized nursing language of hospitalized patients with type 2 diabetes was formed. Results The standardized nursing language of hospitalized patients with type 2 diabetes included six nursing diagnoses，11 nursing outcomes，52 nursing indicators，15 nursing measures and 126 nursing activities. Conclusion The standardized language of core nursing procedures for hospitalized patients with type 2 diabetes constructed in this study is in line with China’s national conditions，cultural background，language understanding and clinical practice. It is professional and scientific，which is conducive to achieving the standardization of nursing language and improving the quality of diabetes specialty nursing.

Key words: Diabetes Mellitus, Type 2, Nursing diagnosis, Classification of nursing outcomes, Classification of nursing measures

靳荣秀, 郭晶晶, 刘素琼, 彭卫群. 2型糖尿病住院患者核心护理标准化语言的构建[J]. 中华护理教育, 2024, 21(7): 887-891.

JIN Rongxiu, GUO Jingjing, LIU Suqiong, PENG Weiqun. Construction of standardized nursing language for hospitalized patients with type 2 diabetes[J]. Chinese Journal of Nursing Education, 2024, 21(7): 887-891.

图/表 2

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