摘要
目的查找分析护士在日常使用纸质版谵妄意识模糊快速评估量表(3D-CAM)过程中的问题,以期为3D-CAM的智能化开发提供依据。方法采用便利抽样法,选择北京市某三甲医院谵妄高发骨科17名护士为研究对象,于2018年5-6月使用纸质版3D-CAM进行日常谵妄评估;研究者通过任务走查法观察和记录护士在纸质版3D-CAM日常使用过程中存在的问题,直到不再出现新问题时,即达到资料饱和状态,停止资料收集。结果17名骨科护士日常使用纸质版3D-CAM对57例患者进行了 107次评估,本研究通过任务走查法发现护士在日常使用纸质版3D-CAM时出现差错的主要原因有“人因失误” 30次,“条目内容理解有误” 7次,“条目内容理解不足” 30次,“护理记录不完整/缺失” 6次。结论护士使用纸质版3D-CAM进行谵妄评估错误率高、可用性较差,故应加强护士谵妄评估的训练,同时对3D-CAM等谵妄评估工具进行智能化的开发设计,将其整合到医院信息化系统中,实现谵妄评估信息化、规范化、标准化。
Objective To identify and analyze the problems existing in nurses' daily use of 3-Minute Diagnostic Interview for CAM-Defined Delirium (3D-CAM) and to provide a basis for intelligent development of 3D-CAM. Methods From May to June 2018, totally 17 nurses who used printed 3D-CAM for daily evaluation of delirium in the Department of Orthopedics with a high incidence of delirium in a Class Ⅲ Grade A hospital in Beijing were selected by convenient sampling. Researchers observed and recorded the problems in nurses' daily use of 3D-CAM by task-centered walkthrough method till no new problems were found, i.e., the data were saturated and the data collection was completed. Results The 17 orthopedic nurses used printed 3D-CAM for 107 evaluations of 57 patients. According to the walk-through research, it was found that the main causes of misuse of 3D-CAM were "man-made errors"(n=30),"misunderstanding of items"(n=7),"insufficient understanding of items"(n=30), and "incomplete/missing nursing records"(n=6). Conclusions Nurses' use of printed 3D-CAM for delirium evaluation showed a high error rate and poor availability. Therefore, we need to enhance the training of delirium evaluation for nurses, conduct intelligent design and development of 3D-CAM and other delirium evaluation tools, and integrate them into the information system of hospitals so as to achieve the informatization, normalization and standardization of delirium evaluation.
作者
韩媛
张山
吴瑛
Han Yuan;Zhang Shan;Wu Ying(School of Nursings Capital Medical University, Beijing 100069, China)
出处
《中华现代护理杂志》
2019年第13期1619-1624,共6页
Chinese Journal of Modern Nursing
基金
国家自然科学基金国际(地区)合作与交流项目(71661167008).
关键词
护士
谵妄
评估
问题分析
智能化
Nurses
Delirium
Evaluation
Problem analysis
Intelligent
