老年综合评估护理信息管理系统的开发与临床应用  

Development and clinical application of comprehensive geriatric assessment nursing information management system

作　　者：王洁 莫永珍 郭妍 史晓兰 陈立瑜 Wang Jie;Mo Yongzhen;Guo Yan;Shi Xiaolan;Chen Liyu(Department of Nursing, Geriatric Hospital of Nanjing Medical University, Nanjing 210024, China;Department of Surgery, Geriatric Hospital of Nanjing Medical University, Nanjing 210024, China;Department of Geriatrics, Geriatric Hospital of Nanjing Medical University, Nanjing 210024, China)

机构地区：[1]南京医科大学附属老年医院护理部,南京210024 [2]南京医科大学附属老年医院外科,南京210024 [3]南京医科大学附属老年医院老年科,南京210024

出　　处：《中华现代护理杂志》2019年第18期2266-2269,共4页Chinese Journal of Modern Nursing

基　　金：江苏省干部保健课题(BJ16024).

摘　　要：目的开发老年综合评估护理信息管理系统,探讨其临床应用价值。方法将老年综合评估与移动护理信息系统相结合,设计与开发老年综合评估护理信息管理系统。采用便利抽样法,选取2018年4月1日—6月30日入住南京医科大学附属老年医院的196例老年住院患者作为研究对象。由经统一培训的护理人员运用上述系统对住院老年人进行管理,包括入院时及出院前的老年综合评估、持续的老年综合评估干预,用出入院老年综合评估各项目的变化评价老年综合评估护理信息管理系统的临床应用效果。结果老年综合评估护理干预实施情况与老年综合评估护理标准的相符率为67%~91%。与入院时相比,老人出院时疼痛评分评分下降(P<0.01),营养不良评分、压疮评分、跌倒评分、ADL评分的变化差异无统计学意义(P>0.05)。结论老年综合评估护理信息管理系统有助于临床老年综合评估的实施,监测老年综合评估干预效果,便于护理管理者进行护理质控,值得在临床及社区推广应用。Objective To develop the comprehensive geriatric assessment (CGA) nursing information management system and to explore its application value. Methods CGA and mobile nursing information system were combined to design and develop the CGA nursing information management system. Totally 196 geriatric inpatients admitted in Geriatric Hospital of Nanjing Medical University from April 1st to June 30th, 2018 were selected using convenient sampling. These geriatric patients were managed by the well-trained nursing staff using the system, including CGA at admission and before discharge and continuous CGA. The changes of CGA at admission and discharge were used to assess the clinical application value of the CGA nursing information management system. Results The consistency rate of the implementation of CGA nursing intervention with CGA nursing norms was 67%-91%. The geriatric patients' pain scores at discharge decreased compared with those at admission (P<0.01), but there was no statistically significant difference in malnutrition risk, pressure ulcer, fall and ADL scores (P>0.05). Conclusions The CGA nursing information management system is conductive to the implementation of CGA clinically, the monitoring of the effects of CGA nursing intervention, and the nursing quality control by nursing managers, which is worth promoting clinically and in communities.

关 键 词：老年人 老年综合评估 移动护理 护理信息管理系统 

分 类 号：R47[医药卫生—护理学]