焦点记录法在新生儿应用无创呼吸机护理记录中的应用效果观察  

Observation on the Effect of Focus Recording Method on Neonatal Nursing Record with Non-invasive Ventilator

作　　者：于亚利 刘文娟 霍美池 戴瑞芝 Yu Yali;Liu Wenjuan;Huo Meichi;Dai Ruizhi(Cangzhou Maternal and Child Care Service Centre,Hebei province,Cangzhou City,061001;不详)

机构地区：[1]沧州市妇幼保健院,河北省沧州市061001

出　　处：《中国病案》2022年第9期109-112,共4页Chinese Medical Record

基　　金：沧州市重点研发计划指导项目(204106117)。

摘　　要：目的将焦点护理记录单应用于新生儿无创呼吸机护理记录中,以期达到训练护士思维,改善患儿呼吸状态及治疗,提高工作效率和对护理记录的满意度。方法选取2019年2月1日-2020年5月31日某院收治的应用无创呼吸机正压通气治疗的新生儿136例,根据随机数表法分为焦点组和常规组各68例,常规组采用传统护理表栺记录,焦点组采用焦点护理记录单表栺进行记录,给予相应针对性护理措施,比较2组患儿通气时间和住院时间,观察干预前后2组患儿呼吸状况指标和血气指标,比较2组患儿并发症发生率和护士的满意度。结果焦点组患儿通气时间为3.06±0.31小时和住院时间为7.27±1.46天,明显少于常规组的4.76±0.62小时和9.24±2.32天,差异有统计学意义。干预后焦点组患儿氧合指数为361.58±37.28,高于常规组的309.49±32.61;呼吸指数为0.94±0.15,低于常规组的1.61±0.23,差异有统计学意义;干预后焦点组患儿PaO_(2)和SpO_(2)均高于常规组,PaCO_(2)低于常规组,差异有统计学意义。焦点组患儿并发症发生率为10.29%,明显低于常规组26.47%,差异有统计学意义;焦点组护士对护理记录满意度为93.33%,常规组为73.33%,差异具有统计学意义。结论焦点记录法在新生儿应用无创呼吸机护理记录中的应用后可缩短患儿通气时间和住院时间,改善患儿呼吸状态和血气指标,减少患儿不良反应,提高护士对护理记录的满意度,值得临床推广应用。Objectives This study aims to focus on the application of focus nursing record sheet in the neonatal non-invasive ventilator nursing record,in order to train the nurses’thinking technique,enhance the writing quality of nursing record,improve the breathing condition and treatment of neonatal inpatients,and increase working efficiency and the degree of contentment towards the nursing record.Methods 136 cases of newborn with application of noninvasive ventilator positive pressure ventilation therapy in a hospital from February 1,2019-May 31,2020 were selected and were divided into a focus group and a convention group using the indicator method.The convention group used the traditional nursing form records,while the focus group used the focus nursing record single form and take corresponding nursing measures.Ventilation time and hospitalization time were compared between the two groups.Respiratory status indexes and blood gas indexes were observed before and after intervention.The incidence rate of complications and the nurses’degree of contentment between the two groups was compared.Results The ventilation time(3.06±0.31 hours)and hospital stay(7.27±1.46 days)in the focus group were significantly less than those in the control group(4.76±0.62 hours,9.24±2.32 days),and the differences were statistically significant.After intervention,OI(361.58±37.28)in the focus group was higher than that in the convention group(309.49±32.61),and RI(0.94±0.15)in the convention group was lower than that in the control group(1.61±0.23),with statistical significance.After intervention,PaO_(2) and SpO_(2) in the focus group were both higher than those in the convention group,and PaCO_(2) was lower than that in the convention group,with statistical significance.The incidence rate of complications in the focus group(10.29%)was significantly lower than that in the conventional group(26.47%),and the difference was statistically significant.The nurses’degree of contentment towards the nursing records was 93.33%in the focus group

关 键 词：焦点记录法 新生儿 无创呼吸机 护理记录 应用效果 

分 类 号：R473.72[医药卫生—护理学]