冠状动脉搭桥术围术期临床护理路径的编制  

Establishment of A Perioperative Clinical Nursing Path for CABG

作　　者：魏红蕾[1,2] 吕探云[1] 陆敏敏[1] 林雷[2] 

机构地区：[1]复旦大学护理学院,上海200032 [2]上海交通大学附属第一人民医院护理部

出　　处：《护理学杂志》2009年第4期19-22,共4页

基　　金：上海交通大学附属第一人民医院科学研究基金项目(07A01)

摘　　要：目的编制体外循环下冠状动脉搭桥术（CABG）围术期临床护理路径（CNP）表格，为有效实施临床护理路径提供依据。方法采用数据分析和循证的方法初步拟定CABGCNP文本的构成、CABG各时间段CNP表格样式、各时间段住院日与护理项目，形成CNP表格初稿，经专家咨询和预试验后定稿。结果CABpCNP文本由首页、患者入院情况登记表、CNP表格和变异记录表4部分组成．其中CNP表格包括手术前期（病房）、手术中期（手术室）、手术后期ICU（手术当天）、手术后期ICU（术后第1～2天）和手术后期病房（术后第3～9天）5个时间段的表格；护理内容按检验／检查、评估／措施、药物使用、安全／活动、饮食／营养5个类别制订护理项目；各表格均以“任务-时间”矩阵格式在时间框架中规范护理项目。结论本护理路径项目全面。可作为体外循环下CABG围术期患者的临床护理路径。Objective To construct a perioperative clinical nursing path for CABG（CABG-CNP）, so as to improve nursing quality. Methods By data analysis and evidence-based method, text formation, time intervals and nursing items of the primary CABG-CNP was formed. Experts consultation and preliminary test were conducted to establish the final version. Results The CABG-CNP was composed of 4 parts： the front page, the registration of the patients, the CNP forms and the variance forms. The CNP form consisted of perioperative period（in the ward）, operating period （in the operationroom）, postoperative period（the operation day in ICU）, postoperative period（1-2 days after operation in ICU） and postoperative period（3-9 days after operation in the ward）. Nursing items were arranged in 5 types as laboratory and physical examination, assessment and interventions, drug use, safety and exercises, diet and nutrition, and were standardized by ＂task-time＂ designation. Conclusion The CABG-CNP has complete contents, and can be used in periooerative nursing of CABG.

关 键 词：冠心病 冠状动脉搭桥术 临床护理路径 护理 

分 类 号：R473.6[医药卫生—护理学]