麻醉后监测治疗室患者护理记录指标体系的构建  

Construction of core index system of nursing recording in post anesthesia care unit

作　　者：梁钥 丁红[2] 张广清 王丽梅 肖伦华[2] 陈寒霏 范子博 LIANG Yue;DING Hong;ZHANG Guang-qing;WANG Li-mei;XIAO Lun-hua;CHEN Han-fei;FAN Zi-bo(Dept.Nursing Administration,Nanfang Hospital,Southern Medical University,Guangzhou 510515,China;Dept.of Anesthesiology,Nanfang Hospital,Southern Medical University,Guangzhou 510515,China;Administration Office,Nanfang Hospital,Southern Medical University,Guangzhou 510515,China;School of Nursing,Southern Medical University,Guangzhou 510515,China)

机构地区：[1]南方医科大学南方医院护理部,广东广州510515 [2]南方医科大学南方医院麻醉科,广东广州510515 [3]南方医科大学南方医院院办公室,广东广州510515 [4]南方医科大学护理学院,广东广州510515

出　　处：《护理学报》2023年第6期36-41,共6页Journal of Nursing（China）

基　　金：广东省医学会NOX伤害指数基金项目(GDSA202203001);南方医科大学护理科研专项(Y2021012);广东省护理学会护理科研课题(gdhlxueh2019zl058)。

摘　　要：目的构建科学系统的麻醉后监测治疗室患者护理记录指标体系,为麻醉恢复期的患者安全与护理行为提供依据。方法基于循证理念拟订麻醉后监测治疗室患者护理记录指标体系初稿,采用Delphi专家咨询法向17名专家进行2轮函询,并利用优序图法和百分权重法确定各指标权重。结果2轮专家函询问卷回收率分别为89%、100%,专家权威系数为0.91,变异系数分别为0~0.225、0~0.244,肯德尔协调系数分别为0.209、0.214(P<0.01)。最终形成的麻醉后监测治疗室患者护理记录指标体系包括3项一级指标,10项二级指标和62项三级指标。结论本研究构建的麻醉后监测治疗室患者护理记录指标体系具有良好的科学性和实用性,可为麻醉复苏室护士的临床护理行为与记录具有较好的指导与规范作用。Objective To construct a scientific and systematic nursing record index system for patients in post-anesthesia care unit(PACU),and to provide reference for patient safety and nursing behavior during anesthesia recovery.Methods The draft of evidence-based core index system was developed.Delphi method was used to conduct two rounds of correspondence with 17 experts.By using the precedence chart method and percentage weight method,the weight of each index was calculated.Results The effective recovery rate of the two rounds of expert consultation was 89%and 100%respectively;the expert coefficient of authority 0.91;the coefficient of variation 0~0.225 and 0~0.244 respectively;and the Kendall coordination coefficient 0.209 and 0.214 respectively(P<0.01).The final nursing record index system for patients in PACU consisted of 3 first-level,10 second-level and 62 third-level indicators.Conclusion The nursing record index system for patients in PACU constructed in this study is scientific and practical,and can guide and standardize clinical nursing behavior and recording of nurses in PACU.

关 键 词：麻醉恢复期 麻醉后监测治疗室 PACU 护理记录 护理质量 

分 类 号：R472.3[医药卫生—护理学]