试论护理诊断名称命名原则

护理诊断名称命名，是创立护理诊断标准模型的前提，也是进行护理诊断分类的基础。在探讨护理诊断名称命名意义的基础上，针对NANDA护理诊断名称命名存在的问题，提出了护理诊断名称命名需要把握的基本原则。     

论护理诊断在药疗监护中的实践意义

药疗监护事关病人用药安全和疗效.作者认为护理诊断是人们正确认识药物不良反应的必然途径;阐述了病人药物不良反应的护理问题和在护理诊断分类中的实践意义;指出护理诊断是满足病人用药安全和疗效的客观需求,对完善整体护理的层次性和完整性,提高临床护理质量,具有重要的研究价值.     

谈临床医师应正确认识主要诊断

主要诊断是病案首页中的重要信息，是疾病分类的依据。正确填写主要诊断，是临床医师的重要工作。但是由于一些临床医师对主要诊断的认识不足，致使主要诊断选择错误，影响医疗信息的利用。因此，临床医师应正确认识主要诊断，了解书写主要诊断的目的、意义，以便更清楚地界定主要诊断和其他临床诊断。     

临床疾病诊断的正确描述与主要诊断的选择

国际疾病分类ICD－10在我国2001年推广使用，临床医师正确书写疾病诊断是做好疾病牵引和疾病分类统计的关键。并直接到医，教，研中疾病的资料分析研究，使用和质量控制，文章从（1）临床疾病诊断的正确描述，（2）疾病诊断书写存在的主要问题及正确书写。（3）主要诊断的选择原则3个方面进行了阐述。特别是在临床诊断的正确描述中，详细介绍了疾病诊断书写标准，国际疾病分类ICD－10疾病诊断要求。如何合理正确描述疾病诊断等方面的内容，为临床医师掌握疾病诊断的书写规范，进行主要诊断的选择提供可靠的资料。     

临床诊断命名中经常出现的问题

临床诊断名称在各方努力下已日趋规范，因ＩＣＤ－１０对疾病分类部分规则和分类轴心进行了适当调整，临床医师的诊断书写必须适应这一改变。现将日常所见的诊断书写问题结合ＬＣＤ－１０归纳叙述如下。     

国际疾病分类ICD-1O中的假定分类

国际疾病分类中普遍存在假定分类的情况，ICD-9与ICD-10的假定有所不同；假定分类是按临床最常出现的情况进行编码，而在临床上最常出现的情况主要是以西文国家的临床情况为标准，这种情况常常会与我国临床医师的诊断含义矛盾。因此，必须了解和掌握假定分类在国际疾病分类中含义、标识、演化，这样才能更准确地编码。     

多功能护理车的研制和应用

目的：通过改进临床上原有护理车的结构，提高其实用性，避免医护人员在护理过程中带来院内交叉感染的危险。方法：遵循护理管理新理念和临床工作实际需要，研制了多功能护理车。结果：“多功能护理车”获得国家实用新型专利，尤其是医用垃圾可直接分类装袋，减少了院内交叉感染机会，且有警示语时时提醒医护人员进行“三查七对”，提高了医疗安全性。结论：“多功能护理车”结构合理，操作方便、实用，经临床应用，效果满意。     

国际疾病分类ICD-10中的假定分类

国际疾病分类中普遍存在假定分类的情况，ICD-9与ICD-10的假定有所不同；假定分类是按临床最常出现的情况进行编码，而在临床上最常出现的情况主要是以西文国家的临床情况为标准。这种情况常常会与我国临床医师的诊断含义矛盾。因此，必须了解和掌握假定分类在国际疾病分类中含义、标识、演化。这样才能更准确地编码。     

护理诊断应用中存在的问题及原因分析

护理诊断是护理程序的关键步骤，是护士为达到预期结果，选择护理措施的基础。它是分析、综合及判断的过程。临床应用时有一定难度，常常会出现一些错误。现将我院开展整体护理后，护理病历中护理诊断存在的问题，总结如下。     

精神护理过程中临床思维和行为的探讨

运用普遍性和特殊性原理进行护理诊断，能对病人做出较为准确的护理诊断。在进行护理决策时，应运用只因和外因的原理分析产生护亘问题的各种内因和外因，有利于制定措施。把病人疾病转归看成是一个发展过程，运用量变和质变的原理观察病情变化。在护理过程中掌握唯物辩证法，能使临床思维和行为主观上适应病情变化，体现了护理工作的科学性     

浅谈医院专家门诊存在问题及解决对策

专家门诊是医院创建品牌的重要组成部分，在缓解患者就医难，提高患者就医诊治水平等方面发挥着重要作用。本文就目前医院专家门诊存在的问题进行分析，提出了建立专家门诊准入制度，扩大专家门诊，建立专家门诊全程管理制度，提高专家门诊护理质量，做好专家门诊宣传工作，创造良好的患者就医服务环境等解决对策。     

The use of classifications in the practice and teaching of nursing: the experience of the University of Campinas

One of the major aspects of Nursing Process used in nursing graduation courses is Nursing Diagnosis according to North American Nursing Diagnosis Association (NANDA). We've experienced the implementation of systematic nursing care in a school hospital at Campinas, Brazil since nearly one decade. During this time we could evaluate the teaching process as well as searched for data concerning nursing care provided there. We notice that nursing students state the importance of nursing diagnosis and its practical application. Among nursing staff, the classification of nursing practice and diagnosis taxonomy are worth wile, although they find difficulties in stablishing an accurated diagnosis, and evaluation/assessment of nursing care provided. We consider that there is an increasing motivation in using diagnosis; nevertheless, several challenges are to be overcome toward a better clinical reasoning, diagnosis accuracy and refinement of the diagnosis already used in a common basis.     

REMOTE NURSING SERVICES AT ISLAND TOURIST RESORTS

ABSTRACT: Based on a 6 month retrospective analysis of clinic records, the present study reports a detailed profile of nursing services provided for guests at three tropical island tourist resorts. A total of 1183 clinic visits were analysed, with presentations coded according to the International Classification of Primary Care (ICPC). The main reasons for presentation were skin problems, ear disorders, respiratory, digestive and musculoskeletal complaints. Health services consisted mainly of medication, specialist nursing care and first aid. Study findings highlight the importance of using an internationally accepted classification system for primary health research, and the critical role of the nurse in tourist health services.     

两性霉素B脂质体治疗1例胃毛霉菌感染的护理

毛霉菌感染致死率极高,临床上常用两性霉素B脂质体治疗毛霉菌感染。该文报道某院2011年10月收治的1例胃贲门癌术后伴多发转移合并胃毛霉菌感染的患者的临床护理,通过采用两性霉素B脂质体治疗,在正确的护理评估和护理诊断基础上,予以全面的精心护理,患者病情渐趋稳定出院。     

Incorporation perspectives of the International Classification for Nursing Practice (ICNP) in Brazil

In this paper some aspects concerning the nursing classification systems are discussed, with emphasis in the International Classification for Nursing Practice (ICNP) and the perspectives of its incorporation in Brazilian nursing practice. The authors present three Brazilian experiences of incorporation of that classification system: the project of implementation of the language CIPE/CIPESC in electronic record of the Health Department of Curitiba - PR; the project of systematization of nursing care in UTI, that is being developed in Florianópolis - SC; and the development of a technological instrumental, based on the terms used by the nursing team components, for insertion in information systems of a school hospital, in Jo?o Pessoa - PB.     

Nursing staff downsizing at a university hospital

The developed investigation in this type of case study, had as main goal to measure the nursing personnel at a university hospital. The adopted methodology comprizes the identification of some specific variables, among them the patient classification according to the nursing care category and the index of the predicted and not predicted absences. The medical clinic admission and surgical units were studied. Results demonstrated that the current nursing personnel corresponds to 50% of what was expected, whereas the nursing aides personnel has shown an overage of 29.2%. The redefinition of the nurses quantitative in the hospital will create possibilities to reorganize the work with the minimization of the working load, in such a way to assure the quality of delivered nursing care.     

医用多参数监护仪不良事件范围及风险控制

随着现代医疗技术的不断发展,多参数监护仪已成为医院最常用的医疗设备之一,从监护仪的原理和临床应用的角度出发,对监护仪在使用过程中的不良事件范围及风险控制等方面进行了探讨。     

临床护理技术操作考核存在的问题及其对策

随着医学模式的转变，传统的临床护理技术操作考核管理标准，已不能适应“以病人为中心”的整体护理模式和现代护理观的需要，在护理管理和临床工作中，暴露出许多与工作不相适应的问题和矛盾。针对当前形势和要求，迫切需要修订、完善临床技术操作考核评价系统，制定出实用的护理操作技能训练考核的项目、方法、程序及标准，形成一套适应于新形势护理工作的考核模式。     

临床服务中心在优质护理中的作用

目的：探讨临床服务中心在现代医院中存在的意义。方法：分析我院临床服务中心成立三年以来的具体工作,及在临床和病人中产生的效应。结果：为病人提供了一个安静、干净、整洁、温馨的住院环境;把方便送给了病人,把时间还给了护士,加强了无缝隙护理环节管理,减少了医疗隐患;提高了护理质量,促进了护患和谐;降低服务成本,取得了良好社会效益。结论：临床服务中心取得了“患者满意,社会满意,临床满意”效果,促进了临床护理健康发展。