脑血管造影术围手术期表格式护理记录单的应用  

Application of Tabular Nursing Record Sheet in Perioperative Period of Cerebral Angiography

作　　者：卢婷[1] 温贤秀[2] 顾露[3] 雷花[2] 薛朝杨[1] 刘颖[1] Lu Ling;Wen Xianxiu;Gu Lu;Lei Hua;Xue Chaoyang;Liu Ying(Department of Neurology,Sichuan Academy of Medical Sciences,Sichuan Provincial People’s Hospital,Chengdu 610072,Sichuan Province,China;不详)

机构地区：[1]四川省医学科学院·四川省人民医院神经内科,四川省成都市610072 [2]四川省医学科学院·四川省人民医院护理部,四川省成都市610072 [3]四川省医学科学院·四川省人民医院介入室,四川省成都市610072

出　　处：《中国病案》2022年第5期5-7,共3页Chinese Medical Record

基　　金：四川省科技计划项目软科学研究课题(2020JDR0284)。

摘　　要：目的 观察自行设计的脑血管造影术围手术期表格式护理记录单的应用效果。方法 选取2021年3月1日-2021年3月31日收治的122例脑血管造影术患者的表格式护理记录作为观察组,2021年2月1日-2021年2月28日收治的98例脑血管造影术患者的传统护理记录作为对照组。比较2组护理文书书写缺陷发生率、护理文书书写时间、护理文书书写质量及围手术期管理质量。结果 观察组护理文书书写缺陷例数为34例,缺陷发生率为34.69%,对照组为6例,缺陷发生率为4.92%,观察组缺陷发生率明显低于对照组;观察组护理文书书写时间为14.74±1.34分钟,明显低于对照组的29.04±1.56分钟;观察组护理文书书写质量和围手术期管理质量得分分别为97.60±0.96分、97.44±1.04分,明显高于对照组的88.73±2.38分、84.81±1.45分。结论 表格式护理记录单的应用可降低护理文书书写缺陷率,减少护理文书书写时间,提高护理工作质量,同时对护士完成脑血管造影术患者围手术期的护理工作具有指引作用,值得推广应用。Objectives To observe the application effect of self-designed tabular nursing record sheet in perioperative period of cerebral angiography.Methods The tabular nursing records of 122 patients with cerebral angiography treated from March 1st,2021 to March 31st,2021 were selected as the observation group,and the traditional nursing records of 98 patients with cerebral angiography treated from February 1st,2021 to February 28th,2021 were selected as the control group.The rate of writing defects,writing time,writing quality and perioperative management quality were compared between the two groups.Results There were 34 cases of nursing document writing defects in the observation group,and the defect incidence rate was 34.69%.There were 6 cases in the control group,and the defect incidence rate was 4.92%.The defect incidence rate in the observation group was significantly lower than that in the control group.The writing time of nursing documents in the observation group was 14.74±1.34 minutes,which was significantly lower than that of the control group 29.04±1.56 minutes.The scores of writing quality of nursing documents and perioperative management quality in the observation group were 97.60±0.96 and 97.44±1.04,which was significantly higher than that of the control group 88.73±2.38 and 84.81±1.45.Conclusions The application of tabular nursing record sheet could reduce the rate of writing defects in nursing records,the writing time of nursing records,improve the quality of nursing work,and guide nurses to complete the nursing work of patients with cerebral angiography during perioperative period,which was worth popularizing.

关 键 词：脑血管造影术 围手术期 表格式护理记录单 

分 类 号：R47[医药卫生—护理学]