CN113889255A - Nursing whole-course care management system and management method thereof - Google Patents
Nursing whole-course care management system and management method thereof Download PDFInfo
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Abstract
The invention discloses a nursing whole-course care management system and a management method thereof. In one aspect, the invention provides a nursing full-course care management system, which comprises a first login end for medical staff to login and a second login end for patient to login, and further comprises the following modules; the system comprises a recording and analyzing system, a case record retrieval module, a care knowledge base module and an active research type database, wherein the recording and analyzing system, the case record retrieval module and the care knowledge base module form a normal model research type database for recording and analyzing the whole care process of the radical bladder cancer surgery; the first login end, the second login end and the normal model research type database are respectively connected with a comprehensive processing platform, and the active research type database is connected with the normal model research type database. On the other hand, the invention also provides a whole-course nursing management method for nursing. The invention can effectively analyze the nursing problem, provide effective nursing decision and intervention and improve the nursing effect.
Description
Technical Field
The invention belongs to the technical field of nursing, and particularly relates to a nursing whole-course care management system and a nursing whole-course care management method.
Background
Bladder cancer is one of the common malignancies of the urogenital system of the elderly. Radical cystectomy and urinary diversion are the golden standard for treating invasive bladder cancer, and orthotopic neocystectomy, ileal cystectomy and uretero-dermostomy are 3 common urinary diversion methods. The average hospitalization day is a comprehensive index for evaluating the medical quality and technical level as well as the medical efficiency and benefit of the hospital. The technical support of the patient's ' recovery back to the community ' and ' medical care combination ' policies and accelerated rehabilitation surgery is a powerful guarantee for shortening the average hospitalization day, and accompanying the problems of early discharge of the patient without complete recovery, multidisciplinary cooperation and the like, the nursing work is very important.
As health services systems gradually regress toward increased benefit and efficiency, the effects of care will continue to be unseen from measurement without relevant data to support the benefit of care practices and the contribution of care to patient outcomes. From the 80 s of the 20 th century to the present, clinical effect evaluation methods have been shifted from curative effect evaluation methods to outcome evaluation methods, the former evaluate the postoperative biological characteristics of patients according to the clinical experience of the patients (such as mortality, morbidity, clinical signs), the results have one-sidedness and subjectivity, and the latter dynamically reflect the subjective experience of the patients through objective data persistence. The outcome of care is recognized by the international care community as an important identifier that encourages care professions to distinguish them as unique specialties from other medical disciplines. Care programs are important elements in influencing the mechanisms that improve the outcome of care. Learners predict that care program development will enter the model care phase, i.e., care prototypes determined by caregivers using a computer system to provide services based on the occurrence and usage of specific patient group care diagnoses, care measures, and care outcomes; meanwhile, nursing staff can refer to remote first-level, second-level and third-level nursing data of similar cases in other hospitals, and the nursing service provided for the patients is optimized. The essence of model care is to optimize patient outcomes through data mining.
According to the above, cooperation between the patient and the medical care personnel and timely nursing intervention according to the feedback of the patient can effectively improve the nursing effect, so that a whole-course nursing management system for nursing is needed.
Disclosure of Invention
The invention aims to provide a nursing whole-course care management system, which can effectively analyze nursing problems, provide effective nursing decision and intervention and improve nursing effect.
The second objective of the present invention is to provide a management method of the above system.
In order to realize the first purpose, the invention provides a nursing management system in whole nursing process, which comprises a first login end for medical staff to login and a second login end for patient to login, and also comprises the following modules;
recording and analysis system: the system is used for recording basic information, nursing problems, nursing intervention and nursing fate of a patient in the whole course of bladder cancer radical treatment, recording evaluation results, intervention types, intervention directions and nursing fate evaluation scores of the patient at different time points by clicking existing standard terms of a selected database, and extracting the incidence rate, the usage rate of the intervention types and the intervention directions and the dynamic change of the nursing fate of the patient at different time points in different fields of bladder cancer radical treatment;
case record retrieval module: the system is used for inputting key information of a patient, checking related records and data analysis results of the patient and enabling medical personnel to obtain similar case care information;
the care knowledge base module: the system is used for a nurse to click the narrative nursing strategy system and the patient outcome evaluation knowledge system of the bladder cancer radical operation patient which are constructed by the inquiry, wherein the patient outcome evaluation knowledge system relates to four fields of relevant behaviors of environment, social psychology, physiology and health;
active research type database: for debilitating and nutritional management;
the recording and analyzing system, the case record retrieval module and the care knowledge base module form a normal model research database for recording and analyzing the whole care process of the radical bladder cancer operation;
the first login end, the second login end and the normal model research database are respectively connected with a comprehensive processing platform for connection and calling among the modules, and the active research database is connected with the normal model research database.
Preferably, the active research database comprises a weakness management system and a nutrition management system, wherein the weakness management system and the nutrition management system are respectively provided with an evaluation module, a decision-making module, an early warning module and a guidance module;
in the nutrition management system, an evaluation module scores the disease state and nutrition state items in the NRS2002 scale, a decision module intelligently analyzes acquired data through a preset standard of the system to make decision judgment, an early warning module judges the risk degree of a patient according to the score condition of the patient, so as to evaluate the risk level and send out early warning signals of different levels, a guide module determines a corresponding intervention strategy through the matching formulation and inspection of a literature law and an interview law, and the literature law is used as the standard when the literature law and the interview law conflict;
in the weakening management system, an evaluation module adopts a Fried weakening phenotype scale for grading, a decision module intelligently analyzes acquired data through a preset standard of the system to make decision judgment, an early warning module judges the risk degree of a patient according to the scoring condition of the patient so as to evaluate the risk grade and send out early warning signals of different levels, a guide module determines a corresponding intervention strategy through the matching formulation and inspection of a literature method and an interview method, and the literature method is used as the standard when the literature method conflicts with the interview method.
Preferably, the active research database is connected with the recording and analyzing system, the normal research database is further provided with a real-world conventional database for recording basic information of caring patients, nursing problems, nursing interventions and nursing outcomes and patient nursing feedback information in the whole process of the radical bladder cancer operation, summarizing and recording the basic information, nursing problems, nursing interventions and nursing outcomes and patient nursing feedback information, and facilitating the examination and providing of nursing information, and the active research database and the recording and analyzing system are connected with the real-world conventional database.
In order to realize the second purpose, the invention provides a nursing management method in the whole nursing process, which comprises the following processing steps,
step 1: the personal information and nursing related information of the patient are recorded by the recording and analyzing system, and the recording and analyzing system forms a nursing flow and related data aiming at the patient according to the nursing knowledge base module;
step 2: after logging in, medical staff input key information of a patient through a case record retrieval module, and a record and analysis system pushes relevant information of the patient, nursing processes and relevant data to be used for the medical staff to know a nursing process;
and step 3: the recording and analyzing system regularly pushes related questionnaires to the patient for summarizing and obtaining the evaluation results, intervention types, intervention directions and nursing outcome evaluation scores of the patient at different time points and feeding the feedback information of the patient back to related medical care personnel;
and 4, step 4: nutrition and weakness evaluation is carried out on a patient after the patient is admitted, data are synchronously imported into a decision module of an active research type database for analysis, if nutrition and weakness early warning exists in the patient, the patient automatically enters the active research type database through a recording and analyzing system, a responsibility nurse is allowed to select corresponding measures through a guide module of a weakness management system and a guide module of a nutrition management system, and finally, nursing intervention records are automatically generated and linked to a recording and analyzing system for reference use of medical care personnel.
Preferably, in step 1, after the patient information is recorded, the recording and analyzing system evaluates the patient according to a preset standard to obtain the existing and potential nursing problems, obtains the level of the problem needing intervention, carries out sequential treatment and sequencing on the problems, and then forms an intervention plan, a target and a nursing implementation scheme according to an intervention scheme table in the care knowledge base module;
the intervention scheme table takes an Olympic intervention system as a framework and consists of three parts, namely: the intervention classes established by taking the first level of the intervention scheme of the Olympic system as a framework comprise four classes: educational guidance and counseling, treatment and procedure, case management, monitoring; a second part: making an intervention direction according to a second level of the intervention scheme of the Olympic system; and a third part: based on prior survey results and literature reports, intervention measures are made as needed by care measures to classify entries in the NIC relating to elderly patients and the urinary system.
Preferably, in step 3, after the feedback information of the patient is obtained, the recording and analyzing system performs evaluation again by combining the active research database according to the feedback information and the recorded patient information to obtain the existing and potential nursing problems, the level of the problem needing intervention is obtained to perform sequential treatment and sequencing on the problems, and then the intervention plan, the target and the nursing implementation scheme are changed according to the care knowledge base module.
Preferably, the proactive research database is pushed to patients and related medical personnel by assessing debilitating and nutritional management decisions and periodically making nursing guidance reminders.
Preferably, the recording and analyzing system summarizes the patient's care information, intervention information and results and the patient's feedback in real time to refine the patient's corresponding care case so as to refine the real-world conventional database for easy reference and review of care.
Preferably, the first and second electrodes are formed of a metal,
the process of summarizing and perfecting the care case corresponding to the patient is carried out through an implementation process and an optimized care ending process;
the implementation flow comprises the following steps,
the first step is as follows: evaluating general data, physiological conditions, psychosocial conditions, health-related behaviors, medical history and treatment conditions of the patient according to preset standards;
the second step is that: determining care questions and performing pre-intervention K-B-S scoring on each question according to analysis of symptoms/signs included in the assessment results, wherein the assessment at least comprises: patient urodynamics examination results, drinking water and diet arrangement conditions, whether to take drugs affecting urination, nocturnal urination times, sleep problems, mastered and most understood disease and surgical knowledge, intestinal complications and surgical history, preoperative enema preparation conditions, expected values for surgical effects; the evaluation mode is face-to-face interview, observation and nursing physical examination according to preset standards;
the third step: grading the nursing problems after intervention, and comparing the improvement conditions before and after the intervention; checking the implementation condition of each intervention, evaluating the latest condition of the patient and the family, determining a new problem, and completely evaluating the existing and potential nursing problems of the patient by continuing four fields of the Omaha system problem classification table after the patient is discharged; wherein the evaluating comprises at least: the number of urination at night, sleep problems, satisfaction with post-operative effects, compliance with pre-operative and post-operative bladder training, self-care conditions, home environment after discharge, and the ability of patients and family members to identify and handle post-operative abnormal symptoms; the assessment mode during the hospitalization period is carried out through face-to-face interview, observation and reading of medical records and related laboratory and imaging data and nursing physical examination according to a preset standard, and the assessment mode after discharge is carried out through the interview record of a telephone to be assessed according to the preset standard;
the fourth step: analyzing potential nursing problems of the patient according to the existing nursing problems and the K-B-S score of the patient, and making expected targets and nursing measures together with doctors, patients and family members; analyzing whether new problems and intervened problems of the patient reach the expected target or not, and adjusting intervention measures;
the optimized nursing ending process comprises the steps of determining existing problems according to cognitive assessment-knowledge mastering and application conditions of a patient, analyzing reasons and formulating corresponding measures to solve the problems; the cognitive assessment method comprises the steps of adopting an Olympic System success evaluation scale to carry out cognition and behavior scoring on self care problems of a patient, analyzing whether behaviors reach an expected target or not if cognition change reaches the expected target, analyzing the mastering degree and application condition of knowledge of the patient on the basis, determining the problems existing in the patient and classifying the problems to form three categories of knowledge defects, knowledge transformation dyskinesia and wrong health beliefs.
Compared with the prior art, the invention has the beneficial effects that:
according to the invention, the recording and analyzing system, the case record retrieval module and the care knowledge base module are arranged to form a normal model research database and are combined with the active research database, so that the information and feedback of patients can be analyzed, and nursing decision and intervention are provided, thereby improving the nursing effect, ensuring that nursing staff can clear the problem of care and implement prospective care. According to the invention, the active research type database is arranged for management analysis of weakness and nutrition, so that cooperative medical care personnel in the nursing process can be effectively improved, and the management effect of weakness and nutrition can be improved. According to the invention, reference and data support can be improved for subsequent nursing work by perfecting the real world conventional database, and nursing knowledge and strategy of the patient with radical bladder cancer are perfected.
Drawings
FIG. 1 is a schematic structural view of the present invention;
FIG. 2 is a block diagram of the encouraging method of the present invention.
Detailed Description
The technical solutions of the present invention are further described in detail below with reference to the accompanying drawings, but the scope of the present invention is not limited to the following.
As shown in fig. 1, the present invention provides a nursing management system for whole nursing care, which includes a first login end 1 for medical staff to login and a second login end 2 for patient to login, and further includes the following modules;
recording and analysis system 3: the system is used for recording basic information, nursing problems, nursing intervention and nursing fate of a patient in the whole course of bladder cancer radical treatment, recording evaluation results, intervention types, intervention directions and nursing fate evaluation scores of the patient at different time points by clicking existing standard terms of a selected database, and extracting the incidence rate, the usage rate of the intervention types and the intervention directions and the dynamic change of the nursing fate of the patient at different time points in different fields of bladder cancer radical treatment; wherein, the basic information of the patient comprises the name, the telephone, the ID card number, the address, the age and the history of allergy;
case record retrieval module 4: the system is used for inputting key information of a patient, checking related records and data analysis results of the patient and enabling medical personnel to obtain similar case care information;
the care knowledge base module 5: the system is used for a nurse to click the narrative nursing strategy system and the patient outcome evaluation knowledge system of the bladder cancer radical operation patient which are inquired and constructed, wherein the patient outcome evaluation knowledge system relates to four fields of relevant behaviors of environment, social psychology, physiology and health;
active research type database 7: for debilitating and nutritional management; in this embodiment, when the active research database 7 is in operation, one is a research based on a real-world data system under a specific and relatively single research assumption; another approach is to build a research-type database on the basis of the overall research objective, answering multiple hypotheses for solving multiple problems.
The recording and analyzing system 3, the case record retrieval module 4 and the care knowledge base module 5 form a normal model research type database 6 for recording and analyzing the whole care process of the radical bladder cancer surgery;
the first login end 1, the second login end 2 and the normal model research type database 6 are respectively connected with a comprehensive processing platform 8 for connection and calling among the modules, and the active research type database 7 is connected with the normal model research type database 6.
In this embodiment, the physiological fields include urinary function, circulatory function, pain, nerve-muscle-bone function, digestion-hydration, defecation function, infection/infection status, urination, peripheral tissue perfusion, cognitive orientation, postoperative rehabilitation status, ostomy care, bed exit activity, respiratory status, postoperative rehabilitation status, electrolyte and acid-base balance, defecation continence, infection severity, and the like. The psychosocial areas include mental health, social interaction, anxiety levels, social competence, social engagement, and the like. The health-related behavioral areas include nutrition, sleep and rest patterns, physical activities, health care supervision, personal care, medication regimens, rest, sleep, knowledge of diabetes management, knowledge of prescription activities, discharge preparation 1 (independent life), discharge preparation 2 (life to support), activities of daily living, knowledge of medication, and the like. Environmental fields include safety, prevention of fall behavior, etc.
The active research type database 7 comprises a weakness management system and a nutrition management system, wherein the weakness management system and the nutrition management system are respectively provided with an evaluation module, a decision-making module, an early warning module and a guidance module,
in the nutrition management system, an evaluation module scores by using disease state and nutrition state items in an NRS2002 scale, a decision module intelligently analyzes acquired data through a preset standard of the system to make decision judgment, an early warning module judges the risk degree of a patient according to the score condition of the patient, so that the risk grade is evaluated, early warning signals of different levels are sent out, and a guidance module determines a corresponding intervention strategy through the matching formulation and inspection of a literature method and an interview method. When the corresponding intervention strategy formed by the guidance module is detected and determined through the literature method and the interview method, the literature method is used as the standard when the literature method and the interview method conflict.
In this embodiment, the nutritional assessment in the assessment module is completed immediately after admission; timely assessment by score > 15 according to changes in activity content, (at least once every three days); < 14 points evaluated weekly. The decision module is used for supporting treatment according to the setting that the risk of malnutrition is greater than or equal to 3; <3 taps were subjected to major surgery, and re-evaluated weekly. If the patient is determined to be a high-risk patient in the early warning module, firstly, the total score of the patient is taken as an early warning color by a visual management theory, and the selected basis is presented by a red score; when re-evaluation is needed every week, the next operation cannot be performed in the automatic research database and the normal database if the re-evaluation is not performed.
The health education guidance and consultation in the guidance module comprises the influence of nutrition on postoperative complications; nutritional support regimen treatments and procedures; feeding fluid enteral nutrition support 1 day before operation; short peptide total nutrient with energy of 20kcal/kg and protein of 1.2 g/kg; optimizing parenteral nutrition therapy after surgery; total in one venous nutrition, energy 25kcal/kg, protein 1.2g/kg, glycolipid ratio 2: 1, hot nitrogen ratio 100: 1 contains vitamins, trace elements and electrolyte; early fluid enteral nutritional support after surgery; after 1-2 days, the fluid is cleared and transits to short peptide type full nutrients according to the tolerance condition of a patient. The individual case management is the special nutrition department and the special diabetes department if necessary. Monitoring for observation of gastrointestinal symptoms in a patient; and analyzing the blood sugar monitoring result. Managing each case: if necessary, the nutrition and diabetes departments are switched. Monitoring: observing gastrointestinal symptoms in the patient; and analyzing the blood sugar monitoring result.
In the weakening management system, an evaluation module adopts a Fried weakening phenotype scale for grading, a decision module intelligently analyzes acquired data through a preset standard of the system to make decision judgment, an early warning module judges the risk degree of a patient according to the scoring condition of the patient so as to evaluate the risk grade and send out early warning signals of different levels, and a guidance module determines a corresponding intervention strategy through the matching formulation and inspection of a literature method and an interview method. When the corresponding intervention strategy formed by the guidance module is detected and determined through the literature method and the interview method, the literature method is used as the standard when the literature method and the interview method conflict.
In this embodiment, the assessment module includes weight loss of unknown cause, self-reported fatigue, reduced physical activity, decreased walking speed, and low grip strength. The decision module is standardized to have three or more clinical indicators diagnosed as debilitating syndrome; less than three are in the early stage of asthenia. If the patient is determined to be an infirm patient in the early warning module, the early warning color is red, and the early stage of infirm is marked as orange; when re-evaluation is needed every week, the next operation cannot be performed in the automatic research database and the normal database if not performed.
The exercise circulation training in the guidance module comprises training contents including stretching exercise, balance training, resistance exercise and cooling exercise; before operation, 7 parts per day: 00-8: 00, carrying out exercise circulation training, wherein 30min each time, within 3d after operation, a responsibility nurse guides the bed to move, and after operation, the bed is discharged from a hospital for 4d, and carrying out balance training and upper limb resistance exercise. The nutrition transition support comprises perioperative diet transition nutrition department, and an organization dietician participating in a group conference to discuss the weekly diet plan of the patient, adjust timely according to the condition of the patient, provide personalized nutrition support, and supplement vitamin D and protein. Cognitive training and mental health management includes providing personalized cognitive function training for patients with mild cognitive impairment; relay psychological consultants if necessary.
The active research type database 7 is connected with the recording and analyzing system 3, the normal model research type database 6 is also provided with a real world conventional database which is used for recording basic information, nursing problems, nursing intervention and nursing outcome and patient nursing feedback information of the bladder cancer radical treatment patient in the whole process, summarizing and recording the basic information and the nursing information of the patient, and is convenient to check and provide nursing information, the active research type database 7 and the recording and analyzing system 3 are connected with the real world conventional database, wherein the real world research database collects nursing data generated in the individualized advanced nursing practice process of the elderly bladder cancer radical treatment patient based on a database platform to form a nursing prototype, prospective nursing is implemented, the nursing service provided for the patient is optimized, and the nursing effect of the patient is improved.
As shown in fig. 2, the present invention further provides a nursing care management method, which comprises the following steps,
step 1: the personal information and nursing related information of the patient are recorded by the recording and analyzing system 3, and the recording and analyzing system 3 forms a nursing process and related data aiming at the patient according to the nursing knowledge base module 5;
step 2: after logging in, medical staff input key information of patients through the case record retrieval module 4, and the record and analysis system 3 pushes relevant information of patients, nursing processes and relevant data for the medical staff to know the nursing process;
and step 3: the recording and analyzing system 3 regularly pushes related questionnaires to the patient for summarizing and obtaining the evaluation results, intervention types, intervention directions and nursing outcome evaluation scores of the patient at different time points and feeding the feedback information of the patient back to related medical care personnel;
and 4, step 4: nutrition and weakness evaluation is carried out on a patient after the patient is admitted, data are synchronously imported into a decision module of an active research type database 7 for analysis, if nutrition and weakness early warning exists in the patient, the data automatically enter the active research type database 7 from a recording and analyzing system 3, corresponding measures are selected by a responsibility nurse through a guide module of a weakness management system and a guide module of a nutrition management system, and finally, nursing intervention records are automatically generated and linked to the recording and analyzing system 3 for reference use of medical care personnel.
In the step 1, after the patient information is recorded, the recording and analyzing system 3 evaluates the patient according to a preset standard to obtain the existing and potential nursing problems, obtains the level of the problem needing intervention, carries out sequential treatment and sequencing on the problems, and then forms an intervention plan, a target and a nursing implementation scheme according to an intervention scheme table in the care knowledge base module 5;
the intervention scheme table takes an Olympic intervention system as a framework and consists of three parts, namely: the intervention classes established by taking the first level of the intervention scheme of the Olympic system as a framework comprise four classes: educational guidance and counseling, treatment and procedure, case management, monitoring; a second part: making an intervention direction according to a second level of the intervention scheme of the Olympic system; and a third part: intervention measures are formulated as needed by the care measures classification of entries in the nec related to elderly patients and the urinary system according to prior survey results and literature reports.
In step 3, after the feedback information of the patient is obtained, the recording and analyzing system 3 is combined with the active research database 7 to evaluate again to obtain the existing and potential nursing problems according to the feedback information and the recorded patient information, the level of the problems needing to be intervened is obtained to process and sequence the problems, and then the intervention plan, the target and the nursing implementation scheme are changed according to the nursing knowledge base module 5.
The active research database 7 pushes patient and related medical personnel through assessment of development debilitation and nutrition management decisions and regularly attends to nursing guidance reminders.
The recording and analyzing system 3 summarizes the nursing information, intervention information and results of the patient and the feedback of the patient in real time to perfect the nursing case corresponding to the patient, thereby perfecting a real-world conventional database for facilitating nursing reference and viewing.
Summarizing and perfecting the process of the nursing case corresponding to the patient through an implementation process and an optimized nursing ending process;
the implementation flow comprises the following steps,
the first step is as follows: evaluating general data, physiological conditions, psychosocial conditions, health-related behaviors, medical history and treatment conditions of the patient according to preset standards;
the second step is that: determining care questions and performing pre-intervention K-B-S scoring on each question according to analysis of symptoms/signs included in the assessment results, wherein the assessment at least comprises: patient urodynamics examination results, drinking water and diet arrangement conditions, whether to take drugs affecting urination, nocturnal urination times, sleep problems, mastered and most understood disease and surgical knowledge, intestinal complications and surgical history, preoperative enema preparation conditions, expected values for surgical effects; the evaluation mode is face-to-face interview, observation and nursing physical examination according to preset standards;
the third step: grading the nursing problems after intervention, and comparing the improvement conditions before and after the intervention; checking the implementation condition of each intervention, evaluating the latest condition of the patient and the family, determining a new problem, and completely evaluating the existing and potential nursing problems of the patient by continuing four fields of the Omaha system problem classification table after the patient is discharged; wherein the evaluating comprises at least: the number of urination at night, sleep problems, satisfaction with post-operative effects, compliance with pre-operative and post-operative bladder training, self-care conditions, home environment after discharge, and the ability of patients and family members to identify and handle post-operative abnormal symptoms; the assessment mode during the hospitalization period is carried out through face-to-face interview, observation and reading of medical records and related laboratory and imaging data and nursing physical examination according to a preset standard, and the assessment mode after discharge is carried out through the interview record of a telephone to be assessed according to the preset standard;
the fourth step: analyzing potential nursing problems of the patient according to the existing nursing problems and the K-B-S score of the patient, and making expected targets and nursing measures together with doctors, patients and family members; analyzing whether new problems and intervened problems of the patient reach the expected target or not, and adjusting intervention measures;
optimizing the nursing outcome flow comprises determining existing problems according to cognitive assessment-knowledge mastering and application conditions of the patient, analyzing reasons and making corresponding measures to solve the problems; the cognitive assessment method comprises the steps of adopting an Olympic System success evaluation scale to carry out cognition and behavior scoring on self care problems of a patient, analyzing whether behaviors reach an expected target or not if cognition change reaches the expected target, analyzing the mastering degree and application condition of knowledge of the patient on the basis, determining the problems existing in the patient and classifying the problems to form three categories of knowledge defects, knowledge transformation dyskinesia and wrong health beliefs.
In this embodiment, the recording and analyzing system 3 calls the contents of the care knowledge base module 5 and the real world conventional database simultaneously during analysis, so that a complete and accurate care scheme can be formed, and the care effect for the patient after the radical treatment of bladder cancer is improved.
In this embodiment, the medical staff logs in the entry recording and analyzing system 3 through the first login terminal 1 to record the information of the patient, and the recording and analyzing system 3 forms data information corresponding to the nursing process and the nursing intervention according to the information of the nursing knowledge base module 5. Nurses and related medical personnel can obtain nursing information of patients through the case record retrieval module 4 when nursing, so that nursing is convenient and clear. The recording and analyzing system 3 sends a questionnaire aiming at the patient condition to the patient at regular time to summarize and obtain the evaluation results, intervention types, intervention directions and nursing outcome evaluation scores of the patient at different time points, so as to know the requirements and conditions of the patient, and meanwhile, the recording and analyzing system 3 carries out attenuation and nutrition management analysis through the active research type database 7 to form a corresponding intervention scheme so as to improve the subsequent nursing effect. Nutrition and weakness evaluation is carried out on a patient after the patient is admitted, data are synchronously imported into a decision module of an active research type database 7 for analysis, if nutrition and weakness early warning exists in the patient, the data automatically enter the active research type database 7 from a recording and analyzing system 3, corresponding measures are selected by a responsibility nurse through a guide module of a weakness management system and a guide module of a nutrition management system, and finally, nursing intervention records are automatically generated and linked to the recording and analyzing system 3, so that the data are convenient for the medical care personnel to refer and use.
In addition, the invention can be used for the management of patients with urinary system operations, such as prostatic hyperplasia, prostate Ca, kidney operations and the like, besides bladder cancer, without affecting the protection scope of the invention.
The foregoing is merely a preferred embodiment of the invention, it is to be understood that the invention is not limited to the forms disclosed herein, but is not intended to be exhaustive or to limit the invention to other embodiments, and to various other combinations, modifications, and environments and may be modified within the scope of the inventive concept as expressed herein, by the teachings or the skill or knowledge of the relevant art. And that modifications and variations may be effected by those skilled in the art without departing from the spirit and scope of the invention as defined by the appended claims.
Claims (9)
1. A nursing full-course care management system comprises a first login end (1) for medical staff to login and a second login end (2) for patient to login, and is characterized by further comprising the following modules;
recording and analysis system (3): the system is used for recording basic information, nursing problems, nursing intervention and nursing fate of a patient in the whole course of bladder cancer radical treatment, recording evaluation results, intervention types, intervention directions and nursing fate evaluation scores of the patient at different time points by clicking existing standard terms of a selected database, and extracting the incidence rate, the usage rate of the intervention types and the intervention directions and the dynamic change of the nursing fate of the patient at different time points in different fields of bladder cancer radical treatment;
case record retrieval module (4): the system is used for inputting key information of a patient, checking related records and data analysis results of the patient and enabling medical personnel to obtain similar case care information;
a care knowledge base module (5): the system is used for a nurse to click the narrative nursing strategy system and the patient outcome evaluation knowledge system of the bladder cancer radical operation patient which are constructed by the inquiry, wherein the patient outcome evaluation knowledge system relates to four fields of relevant behaviors of environment, social psychology, physiology and health;
active research database (7): for debilitating and nutritional management;
the recording and analyzing system (3), the case recording and retrieving module (4) and the care knowledge base module (5) form a normal model research type database (6) for recording and analyzing the whole care process of the radical bladder cancer surgery;
the first login end (1), the second login end (2) and the normal model research type database (6) are respectively connected with a comprehensive processing platform (8) used for connection and calling among the modules, and the active research type database (7) is connected with the normal model research type database (6).
2. The nursing care management system according to claim 1, wherein the active research database (7) comprises a asthenia management system and a nutrition management system, and the asthenia management system and the nutrition management system are respectively provided with an evaluation module, a decision module, an early warning module and a guidance module;
in the nutrition management system, an evaluation module scores the disease state and nutrition state items in the NRS2002 scale, a decision module intelligently analyzes acquired data through a preset standard of the system to make decision judgment, an early warning module judges the risk degree of a patient according to the score condition of the patient, so as to evaluate the risk level and send out early warning signals of different levels, a guide module determines a corresponding intervention strategy through the matching formulation and inspection of a literature law and an interview law, and the literature law is used as the standard when the literature law and the interview law conflict;
in the weakening management system, an evaluation module adopts a Fried weakening phenotype scale for grading, a decision module intelligently analyzes acquired data through a preset standard of the system to make decision judgment, an early warning module judges the risk degree of a patient according to the scoring condition of the patient so as to evaluate the risk grade and send out early warning signals of different levels, a guide module determines a corresponding intervention strategy through the matching formulation and inspection of a literature method and an interview method, and the literature method is used as the standard when the literature method conflicts with the interview method.
3. The nursing care management system according to claim 1 or 2, wherein the active research database (7) is connected to the recording and analyzing system (3), the normal research database (6) is further provided with a real-world regular database for recording basic information, nursing problems, nursing interventions and nursing outcomes of patients and feedback information of patient nursing during the whole course of bladder cancer radical treatment, summarizing and recording nursing information for easy viewing and providing nursing information, and the active research database (7) and the recording and analyzing system (3) are connected to the real-world regular database.
4. A nursing care management method according to the system of claim 1, comprising the following steps,
step 1: the personal information and nursing related information of the patient are recorded by the recording and analyzing system (3), and the recording and analyzing system (3) forms a nursing flow and related data aiming at the patient according to the nursing knowledge base module (5);
step 2: after logging in, medical staff input key information of a patient through a case record retrieval module (4), and a record and analysis system (3) pushes relevant information of the patient, nursing processes and relevant data to be used for the medical staff to know a nursing process;
and step 3: the recording and analyzing system (3) regularly pushes related questionnaires to the patient for summarizing and obtaining the evaluation results, intervention types, intervention directions and nursing outcome evaluation scores of the patient at different time points and feeding the feedback information of the patient back to related medical staff;
and 4, step 4: nutrition and weakness evaluation are carried out on a patient after the patient is admitted, data are synchronously imported into a decision module of an active research type database (7) for analysis, if nutrition and weakness early warning exists in the patient, the patient automatically enters the active research type database (7) through a recording and analyzing system (3), corresponding measures are selected by a responsible nurse through a guide module of a weakness management system and a guide module of a nutrition management system, and finally, nursing intervention records are automatically generated and linked to the recording and analyzing system (3) for reference use of medical staff.
5. The nursing care management method in the whole course according to claim 4, wherein in step 1, after the patient information is recorded, the recording and analyzing system (3) evaluates the patient according to the preset standard to obtain the existing and potential nursing problems, obtains the level of the problem to be intervened, carries out the sequential treatment and sequencing on the problems, and then forms intervention plan, target and nursing implementation plan according to the intervention plan table in the nursing knowledge base module (5);
the intervention scheme table takes an Olympic intervention system as a framework and consists of three parts, namely: the intervention classes established by taking the first level of the intervention scheme of the Olympic system as a framework comprise four classes: educational guidance and counseling, treatment and procedure, case management, monitoring; a second part: making an intervention direction according to a second level of the intervention scheme of the Olympic system; and a third part: based on prior survey results and literature reports, intervention measures are made as needed by care measures to classify entries in the NIC relating to elderly patients and the urinary system.
6. The nursing care management method in the whole course according to claim 5, wherein in step 3, after the feedback information of the patient is obtained, the existing and potential nursing problems are obtained by the feedback information and the recorded patient information, the recording and analyzing system (3) is combined with the active research database (7) for evaluation again, the level of the problem needing intervention is obtained, the problems are sequentially processed and sequenced, and then the intervention plan, the target and the nursing implementation scheme are changed according to the nursing knowledge base module (5).
7. The method for whole nursing management according to claim 6, wherein the active research database (7) is pushed to the patient and the related medical staff by evaluating the decline and nutrition management decision and carries out nursing guidance reminding at regular time.
8. The nursing care management method according to claim 4, wherein the recording and analyzing system (3) summarizes the nursing information, intervention information and results of the patient and the feedback of the patient in real time to complete the corresponding nursing case of the patient, so as to complete the real-world conventional database for the reference and review of nursing care.
9. The method as claimed in claim 8, wherein the process of summarizing and perfecting the care cases corresponding to the patient is performed by performing a procedure, optimizing a procedure of the care outcome;
the implementation flow comprises the following steps,
the first step is as follows: evaluating general data, physiological conditions, psychosocial conditions, health-related behaviors, medical history and treatment conditions of the patient according to preset standards;
the second step is that: determining care questions and performing pre-intervention K-B-S scoring on each question according to analysis of symptoms/signs included in the assessment results, wherein the assessment at least comprises: patient urodynamics examination results, drinking water and diet arrangement conditions, whether to take drugs affecting urination, nocturnal urination times, sleep problems, mastered and most understood disease and surgical knowledge, intestinal complications and surgical history, preoperative enema preparation conditions, expected values for surgical effects; the evaluation mode is face-to-face interview, observation and nursing physical examination according to preset standards;
the third step: grading the nursing problems after intervention, and comparing the improvement conditions before and after the intervention; checking the implementation condition of each intervention, evaluating the latest condition of the patient and the family, determining a new problem, and completely evaluating the existing and potential nursing problems of the patient by continuing four fields of the Omaha system problem classification table after the patient is discharged; wherein the evaluating comprises at least: the number of urination at night, sleep problems, satisfaction with post-operative effects, compliance with pre-operative and post-operative bladder training, self-care conditions, home environment after discharge, and the ability of patients and family members to identify and handle post-operative abnormal symptoms; the assessment mode during the hospitalization period is carried out through face-to-face interview, observation and reading of medical records and related laboratory and imaging data and nursing physical examination according to a preset standard, and the assessment mode after discharge is carried out through the interview record of a telephone to be assessed according to the preset standard;
the fourth step: analyzing potential nursing problems of the patient according to the existing nursing problems and the K-B-S score of the patient, and making expected targets and nursing measures together with doctors, patients and family members; analyzing whether new problems and intervened problems of the patient reach the expected target or not, and adjusting intervention measures;
the optimized nursing ending process comprises the steps of determining existing problems according to cognitive assessment-knowledge mastering and application conditions of a patient, analyzing reasons and formulating corresponding measures to solve the problems; the cognitive assessment method comprises the steps of adopting an Olympic System success evaluation scale to carry out cognition and behavior scoring on self care problems of a patient, analyzing whether behaviors reach an expected target or not if cognition change reaches the expected target, analyzing the mastering degree and application condition of knowledge of the patient on the basis, determining the problems existing in the patient and classifying the problems to form three categories of knowledge defects, knowledge transformation dyskinesia and wrong health beliefs.
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Cited By (1)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN115762711A (en) * | 2022-10-21 | 2023-03-07 | 东华医为科技有限公司 | Inpatient auxiliary nutrition intervention system, method and device |
Citations (4)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN103455961A (en) * | 2013-09-09 | 2013-12-18 | 丁玉兰 | Patient high risk factor nursing assessment system |
| CN107430641A (en) * | 2015-03-24 | 2017-12-01 | 阿雷斯贸易股份有限公司 | Patient care system |
| CN109259727A (en) * | 2018-08-28 | 2019-01-25 | 苏州德品医疗科技股份有限公司 | A kind of intelligent nursing system based on Mobile nursing |
| CN112614555A (en) * | 2020-12-13 | 2021-04-06 | 云南省第一人民医院 | Method for screening, evaluating and intervening senile syndromes of inpatient elderly patients |
-
2021
- 2021-10-22 CN CN202111235127.8A patent/CN113889255A/en active Pending
Patent Citations (4)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN103455961A (en) * | 2013-09-09 | 2013-12-18 | 丁玉兰 | Patient high risk factor nursing assessment system |
| CN107430641A (en) * | 2015-03-24 | 2017-12-01 | 阿雷斯贸易股份有限公司 | Patient care system |
| CN109259727A (en) * | 2018-08-28 | 2019-01-25 | 苏州德品医疗科技股份有限公司 | A kind of intelligent nursing system based on Mobile nursing |
| CN112614555A (en) * | 2020-12-13 | 2021-04-06 | 云南省第一人民医院 | Method for screening, evaluating and intervening senile syndromes of inpatient elderly patients |
Non-Patent Citations (2)
| Title |
|---|
| 欧阳林: ""互联网+护理"背景下我国移动护理信息管理系统建设研究进展", 《卫生软科学》 * |
| 罗迎霞 等: ""老年膀胱癌根治术护理结局评价指标的构建"", 《护理管理杂志》 * |
Cited By (1)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN115762711A (en) * | 2022-10-21 | 2023-03-07 | 东华医为科技有限公司 | Inpatient auxiliary nutrition intervention system, method and device |
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