肝胆外科入院护理评估单的构建及应用  

Design and application of admission nursing assessment sheet in Department of Hepatobiliary Surgery

作　　者：张红辉[1] 何国平[2] 石泽亚[1] 禹艳群[1] 彭湘群[1] 

机构地区：[1]湖南省人民医院肝胆外科,长沙410005 [2]中南大学湘雅护理学院,长沙410013

出　　处：《中华现代护理杂志》2017年第36期4573-4577,共5页Chinese Journal of Modern Nursing

基　　金：湖南省医药卫生科研项目（B2013-075）

摘　　要：目的 制订全面、合理、具有专科特色的入院护理评估单,提高肝胆外科患者入院护理评估的质量.方法 针对肝胆外科新入院患者的特点及医疗服务的需要,设计适合于肝胆外科住院患者护理评估的评估单,主要包括基本资料、护理体检、生活状态、社会心理状态、专科体检、坠床风险和压疮风险等内容.比较应用前（2014年6月—2015年5月）和应用后（2015年6月—2016年5月）患者坠床、压疮等护理不良事件发生率和患者满意度.结果 应用新版专科入院护理评估单后,住院患者护理不良事件发生率从2.95%下降至0.91%,差异有统计学意义（χ^2=4.386,P〈0.05）;患者满意度从（83.16±10.62）分提高至（90.41±8.66）分,差异有统计学意义（t=14.103,P〈0.05）.结论 新版入院护理评估单多元化多维度地评估患者的入院状况,可降低坠床发生率,降低医疗风险,提高患者满意度,提高护理工作效率,值得在肝胆外科推广应用.Objective To formulate a comprehensive and reasonable admission nursing assessment sheet with specialty features, so as to improve quality of nursing assessment for patients at admission to Department of Hepatobiliary Surgery. Methods According to characteristics of patients newly admitted to Department of Hepatobiliary Surgery and need of medical service,a nursing assessment sheet suitable for inpatients to Department of Hepatobiliary Surgery was designed,with main contents including basic information, physical examinations for nursing,conditions of daily life,social and psychological conditions,specialty examinations,risk of falling down from bed,and risk of pressure sores. Incidence rate of adverse nursing events like patients＇ falling down from bed or pressure sores,and the patients＇ satisfaction were compared before （June 2014 to May 2015） and after （June 2015 to May 2016） application of this sheet. Results After application of this new version of admission nursing assessment sheet,incidence of adverse nursing events happened to inpatients dropped from 2.95% to 0.91% （χ^2=4.386,P〈 0.05）;patients＇ satisfaction increased from （83.16±10.62） to （90.41±8.66） （t=14.103,P〈0.05）. Conclusions By using this new version of admission nursing assessment sheet,status of the patients can be assessed in a diversified and multi-dimensional way,so that incidence of falling down from the bed can be lowered,medical risks be decreases,patients＇ satisfaction be increased,and nursing efficiency be improved,which make it worth promoting in Department of Hepatobiliary Surgery.

关 键 词：入院护理评估单 护理质量 构建 应用 

分 类 号：R473.6[医药卫生—护理学]