精神科护理记录存在的问题以及相关道德要求  

作　　者：郭仕军 

机构地区：[1]江阴市第三人民医院,江苏江阴214400

出　　处：《中国医学装备》2014年第B08期69-70,共2页China Medical Equipment

摘　　要：精神科护理工作具有其特殊性,所面对患者的精神症状复杂多变,对住院患者的护理记录要求范围广、内容复杂、描述准确、记录及时等。因为护理记录不仅只是反映患者在住院期间接受医疗和护理过程中的诊疗记录,同时为患者今后预防复发、检查、治疗提供参考资料,也为医疗护理纠纷提供重要的法律依据。精神科护理工作的对象是患有各种精神疾病的病人,其中病情严重者,表现思维紊乱,行为怪异,丧失生活自理能力。不少病人否认有病,还会造成自伤或影响社会治安。病人的症状往往与生活经历、躯体和精神状态及社会环境、职业、文化背景等诸因素有关,因而形成了精神症状的复杂性,给护理工作带来了一定难度。因此,对护士在道德行为上提出了较高的要求。psychiatric nursing has its particularity, faced complex psychiatric symptoms in patients on inpatient care record requires a wide range of complexity, description is accurate, timely records and so on. Because the record is not just reflected in patient care during hospitalization and medical care during medical records, as well as the prevention of recurrence in patients in the future, examination, treatment to provide reference information, but also provide an important legal basis for health care disputes. Psychiatric care is targeted at patients suffering from various mental disorders, including severe cases, the performance of thought disorder, bizarre behavior, loss of daily living. Many patients deny sick, can also cause self-harm or affect social order. The patient＇s symptoms often associated with life experiences, physical and mental state and social environment, occupational, cultural background and other various factors, thus forming a complex psychiatric symptoms, give care to bring a certain degree of difficulty. Therefore, the nurse at the high ethical demands made

关 键 词：精神科 护理记录 问题分析 道德要求 

分 类 号：R473.74[医药卫生—护理学]