关键词: 临床照护分类系统；护理术语；骨科；护理实践

Abstract: Objective: To explore the application of Clinical Care Classification (CCC) system in orthopedic nursing practice. Methods: The data of the nursing care records using the CCC Full Intelligent Care Information System from March 2019 to July 2019 were analyzed with a total of 263,402 nursing document entries. Results: The data from the CCC system showed that in the nursing diagnosis, the physiological factors accounting for 59.99%, the functional factors accounting for 26.41%, the healthy behavior factors accounting for 9.32%, and the psychological factors accounting for 4.28%. The care measures involved in the integrity of the skin among the nursing elements were the highest (25.47%), followed by the active category (22.25%), the safety category (15.58%) and the body regulation category (14.16%), of which the assessment monitoring category accounted for more than half of the total care measures (50.88%). Nursing implementation measures accounted for 27.43%, while teaching guidance and management referral category measures accounted for 12.03% and 9.66%, respectively; There were significant statistical differences between the expected goal of nursing and the actual outcome. Conclusion: The CCC can be used to record nursing data and write electronic medical records in intensive care unit practice, and can provide personalized care for patients, analyze frequency of each care content, and reduce the amount of work recorded by clinical nurses in nursing documents. It is beneficial to the establishment and analysis of big data in nursing. The application of CCC can promote the clinical practice of orthopedic nursing and the development of nursing research.

Key words: Clinical Care Classification; nursing terminology; orthopedic ward; nursing practice