コンピュータ支援による看護過程・看護診断支援システムの構築と運用―第2報：臨床における実践と結果

Development and Use of a Computerized System to Support Nursing Process and Nursing Diagnosis (Report 2)

　受け持ち看護婦の責任でコンピュータによる看護過程・看護診断支援システムを臨床で運用している．このとき，①P（problems）の診断とN（needs）の診断から患者個別のP＆Nの診断に至る方法や簡素化した記述方法を工夫すると，臨床上の運用が容易になる．また，運用で得られた②患者の状態変化とそれに伴うPの看護診断（NANDA）の出現率，診断に基づく看護介入の方法とそれに要した看護量（時間）を検討した．その結果，Pの診断にNANDAの看護診断分類を用いると，診断は疾病の状態に依存して特異的な経時変化を示すとともに，診断に基づく受け持ち看護婦の看護量も特徴ある変化を示す．これは，NANDAの看護診断分類により病者の状態に特徴的なパターンが抽出でき，対応する看護介入を設定できる可能性を示す．

　We developed and used a computerized system to support nursing process and nursing diagnosis. On the basis of the data obtained during the use of this system, we have studied: (1) methods used to problems (P) and needs (N) in individual cases and means of describing P and N in a simple manner; (2) changes in the conditions of individual patients following the introduction of this system, and the percentage of diagnoses according to NANDA taxonomy; and (3) modes of nursing intervention made on the basis of P diagnosis and the daily nursing activity needed for such interventions. When the NANDA taxonomy was used to identify P, it was found that the diagnosis of P changed specifically, depending on the disease or patient conditions, and that the diagnosis-based daily activities of the primary nurse also showed characteristic changes. This indicates that the NANDA taxonomy allows us to extract response patterns specific to the particular coditions of individual patients and to guide nursing intervention optimal direction.