護理計畫決策支援系統雛型之建立

Development of the Nursing Care Plan Decision Support System

本研究目的在建立護理計劃決策支援系統，包括三個主要步驟：一、以Gordon十一項功能評估作為建構護理評估之基礎，二、以Arden Syntax編輯模組建立決策支援系統之知識庫，並以個人數位助理(PersonalDigitalAssistant,PDA)之機動功能，於資料收集過程中透過無線網路將資料上傳至護理工作站與知識庫連結護理評估資料庫，三、以護理診斷「跌倒」為例，建立「跌倒」評估資料與鑑定性特徵間轉換機制，及護理診斷確立之規則與推論機制。達到下列三項結果：一、護理評估及護理計畫結合並能有效的運用。二、使用PDA方便床邊輸入資料。三、整合護理評估資料即時運用，減少護理人員重複書寫的時間。

The purpose of this study was to develop a 'nursing care plan decision support system.'involving three main steps: (1) the modification of the present nursing assessment form based onthe Gordon functional health pattern assessment concept, (2) using a PDA as a mobile assessmenttool and the Arden-syntax language to set up a decision support system to assist nurses maketimely nursing assessments and appropriate nursing diagnoses, and (3) using one nursing diagnosis'risk of injury/fall' as an example to test the system's function. The successful development of thedecision support system was based on the following points: (1) Existing knowledge of nursingassessments and standard care planning were fully used. (2) A wireless PDA was introduced toenable simple and quick recording of bedside findings. (3) Registered data were optimally reusedupon summarization and readmission to reduce the nurses'workloads.