集成共享疼痛模块化评估记录体系在卵巢癌患者围手术期疼痛管理中的应用  

Integration of a shared pain modular assessment record system for perioperative pain management in ovarian cancer patients

作　　者：蔡丽婷 顾娟[1] 高磊磊 付丽萍[2] 范玉林[3] CAI Liting;GU Juan;GAO Leilei;FU Liping;FAN Yulin(Department of Gynecology,Zhejiang Provincial People,s Hospital,People,s Hospital of Hangzhou Medical College,Hangzhou 310014,China;Department of Gnesthesia and Resuscitation,Zhejiang Provincial People's Hospital,People,s Hospital of Hangzhou Medical College,Hangzhou 310014,China;Information Center,Zhejiang Provincial People's Hospital,People's Hospital of Hangzhou Medical College,Hangzhou 310014,China)

机构地区：[1]浙江省人民医院,杭州医学院附属人民医院妇科,杭州310014 [2]浙江省人民医院,杭州医学院附属人民医院麻醉复苏室,杭州310014 [3]浙江省人民医院,杭州医学院附属人民医院信息中心,杭州310014

出　　处：《浙江医学教育》2022年第4期248-252,共5页Zhejiang Medical Education

基　　金：浙江省医药卫生科技计划项目:“加速康复外科理念下基于智能镇痛管理系统构建急性疼痛服务组织的运作模式”(2020KY014)。

摘　　要：目的探究基于集成共享疼痛模块化评估记录体系在卵巢癌患者围手术期疼痛管理中的应用效果。方法选择2019年至2020年在浙江省人民医院妇科行卵巢癌手术的105例患者作为研究对象。采用试验对照研究方法,将2020年1月~12月入院的52例患者设为试验组,将2019年1月~12月入院的53例患者设为对照组。试验组患者采用疼痛模块化评估记录体系实施疼痛管理,对照组患者采用旧版疼痛评估记录方式指导疼痛管理。通过疼痛评估记录用时、疼痛护理文书缺陷率和护士使用满意度调查结果,比较两组患者疼痛管理效果。结果试验组患者疼痛评估记录用时低于对照组患者,其差异具有统计学意义(P<0.05);试验组患者在疼痛护理记录中未用标准术语率、护理记录缺项漏项率和疼痛曲线缺项漏项率均低于对照组患者,其差异均具有统计学意义(均P<0.05);试验组护士使用满意度6项条目均高于对照组护士,其差异均具有统计学意义(均P<0.05)。结论在卵巢癌患者围手术期疼痛管理中采用疼痛模块化评估记录体系,可以减少疼痛评估记录用时,有利于规范护士疼痛评估行为、降低疼痛护理文书缺陷率,具有较高的护士使用满意度。Objective To investigate the effect of the modular pain assessment recording system based on integrated sharing in perioperative pain management of ovarian cancer patients. Methods Patients admitted to the Department of Gynecology of Zhejiang Provincial People’s Hospital for ovarian cancer surgery from 2019 to 2020 were enrolled as study subjects, of which 53 patients from January to December 2019 were the control group and 52 patients from January to December 2020 were the experimental group. The experimental group received the pain modular assessment record system accepted pain management, while the control group received the old version of pain assessment record to guide pain management. The pain management effect of the two groups was compared by time consumption of pain assessment recording, incidence of defect about pain care documentation and nurse satisfaction. Results The pain assessment and recording time in the experimental group was lower than that in the control group, and the difference was statistically significant(P<0.05). The rate of non-use of standard terms in pain nursing records, the rate of missing items in nursing records, and the rate of missing items in pain curve of patients in the experimental group were lower than those in the control group, and the differences were statistically significant(all P<0.05). The nurses in the experimental group had higher satisfaction with the use of 6 items than those in the control group, and the differences were statistically significant(all P<0.05). Conclusions The use of modular pain assessment and recording system in the perioperative pain management of ovarian cancer patients can reduce pain assessment and recording time, help standardize nurses’ pain assessment behavior, reduce the defect rate of pain care documents and reach a high nurses’ satisfaction.

关 键 词：疼痛评估 围手术期 疼痛管理 模块化 卵巢癌 

分 类 号：R473.71[医药卫生—护理学]