肠造口患者临床护理路径护理信息系统的设计与应用  

Design and application of a nursing information system for enterostomal patients clinical care pathways

作　　者：裴琛[1] 李宁[1] 孙巧玲[1] 张雪[1] 吕颀 赵月 李文桓 周玉洁[2] PEI Chen;LI Ning;SUN Qiaoling;ZHANG Xue;LYU Qi;ZHAO Yue;LI Wenhuan;ZHOU Yujie(Department of Surgery,Peking University Third Hospital,Beijing,100191,China)

机构地区：[1]北京大学第三医院普通外科,北京市100191 [2]北京大学第三医院护理部,北京市100191

出　　处：《中国护理管理》2024年第6期814-818,共5页Chinese Nursing Management

摘　　要：目的:构建基于临床护理路径的肠造口患者护理信息系统,并分析其应用效果,为临床提升造口患者生活质量提供参考。方法:采用文献分析、小组会议法构建肠造口患者临床护理路径,将其嵌入护理信息系统,并于2023年2月在我院普通外科应用。对比系统应用前后肠造口患者入院评估、风险评估、健康教育、疼痛评估、出院评估的完成率及造口自我护理能力,同时调查护士对临床护理路径信息系统的满意度。结果:应用系统后,干预组肠造口患者的入院评估率(100.0%)、风险评估率(94.5%)、健康教育率(100.0%)、疼痛评估率(96.4%)、出院评估率(100.0%)均较系统应用前提高,差异有统计学意义(P<0.05);患者的造口自我护理能力各条目中除使用必要的辅助产品外均有提高,差异有统计学意义(P<0.05),护士的满意度大于90.0%。结论:应用肠造口患者临床护理路径护理信息系统能够有效提高护理措施的落实率,提升肠造口患者的自我护理能力,增进护士对工作的满意度,进而改善患者生活质量。Objective:To construct a nursing information system for enterostomy patients based on clinical nursing pathway and analyze its application effects,so as to provide reference for improving the quality of life in clinical.Methods:The clinical nursing pathway for enterostomal patients was constructed on the basis of literature analysis and using group meeting method,embedded in the nursing information system,and applied from February 2023 till now in the Department of General Surgery of our hospital.We compared the completion rate of admission assessment,risk assessment,health education,pain assessment,discharge assessment,and stoma self-care ability of enterostomy patients before and after the application,as well as the nurses'satisfaction with the clinical nursing pathway information system.Results:After application,the rates of admission assessment(100.0%),risk assessment(94.5%),health education(100.0%),pain assessment(96.4%),and discharge assessment(100.0%)of enterostomy patients in the intervention group improved compared with the previous data,and the differences were statistically significant(P<0.05),and the stoma self-care ability of the patients,except for the use of the necessary auxiliary supplies,improved.The difference was statistically significant(P<0.05),and the nurses'satisfaction was greater than 90.0%.Conclusion:The application of the nursing information system for enterostomal patients based on the clinical nursing pathway can effectively improve the implementation rates of nursing measures,enhance the self-care ability of enterostomal patients,and increase nurses'satisfaction.

关 键 词：肠造口 临床护理路径 护理信息系统 应用 生活质量 

分 类 号：R47[医药卫生—护理学] R197[医药卫生—临床医学]