CAJ | 학술논문

目的：探讨基于国际护理实践分类（ICNP）构建的NICU记录单的应用及临床效果。方法：选取山东省某所三级甲等综合医院NICU的新生儿102例，按入院顺序随机分为观察组和对照组各51例，对照组给予传统护理记录单，观察组使用基于IC-NP构建的NICU记录单，观察比较两组护理记录的书写质量情况、医护人员对监护记录单评价及满意度。结果：观察组护理记录书写质量、医护人员对监护记录单的评价及满意度与对照组比较差异有统计学意义（P＜0.05）。结论：实施基于ICNP构建的NICU记录单，可明显提高护理记录的书写质量，缩短护士书写时间，同时提高新生儿护理质量和医护人员满意度，从而利于促进国际化标准护理语言在我国护理实践中的应用。
목적：탐토기우국제호리실천분류（ICNP）구건적NICU기록단적응용급림상효과。방법：선취산동성모소삼급갑등종합의원NICU적신생인102례，안입원순서수궤분위관찰조화대조조각51례，대조조급여전통호리기록단，관찰조사용기우IC-NP구건적NICU기록단，관찰비교량조호리기록적서사질량정황、의호인원대감호기록단평개급만의도。결과：관찰조호리기록서사질량、의호인원대감호기록단적평개급만의도여대조조비교차이유통계학의의（P＜0.05）。결론：실시기우ICNP구건적NICU기록단，가명현제고호리기록적서사질량，축단호사서사시간，동시제고신생인호리질량화의호인원만의도，종이리우촉진국제화표준호리어언재아국호리실천중적응용。
Objective:To explore the application of NICU record sheet based on International Classification for Nursing Practice(ICNP) and investigate its effect.Methods:102 selected newborns in NICU of a certain general hospital at the level of grade III class A in Shandong province were randomly divided into the observation group and the control group(5 1 cases in each group).The traditional nursing record sheet was used in the control group;the NICU record sheet based on ICNP was used in the observation group.The writing quality of nursing records,the evaluation and satisfaction of medical staff with the sheet were observed and compared between the two groups.Results:There were statistically significant differences in the comparison of the writing quality of nursing records,the evaluation and satisfaction of medical staff with the sheet between the two groups(P<0.05).Conclusion:Application of NICU record sheet based on ICNP can significantly im-prove the writing quality of nursing records,shorten the writing time and improve neonatal nursing quality and satisfaction of medical staff so as to promote the popularization of international standard nursing language in nursing practice in china.