胰腺癌住院患者围手术期营养相关症状自我报告与护理记录一致性研究  

Study on the consistency between self-report of nutrition related symptoms and nursing records of pancreatic cancer inpatients during perioperative period

作　　者：刘璐[1] 智晓旭 陈洁[1] 殷淑芳 LIU Lu;ZHI Xiaoxu;CHEN Jie;YIN Shufang(Department of General Surgery,the Affiliated Cancer Hospital of Nanjing Medical University/Jiangsu Cancer Hospital/Jiangsu Institute of Cancer Research,Nanjing 210009,China)

机构地区：[1]南京医科大学附属肿瘤医院/江苏省肿瘤医院/江苏省肿瘤防治研究所普外科,江苏南京210009

出　　处：《医药高职教育与现代护理》2024年第6期470-474,共5页Medical Higher Vocational Education and Modern Nursing

基　　金：江苏省老年健康科研项目(LKM2022013);江苏省肿瘤医院临床科技攀登计划护理研究专项(ZH202211);江苏省肿瘤医院临床科技攀登计划护理研究专项(ZH202111)。

摘　　要：目的调查并探讨胰腺癌患者围手术期对自身营养相关症状自我报告与护理记录之间的一致性。方法采用便利抽样法,选取2022年1月至2022年12月某肿瘤专科医院(三甲医院)胰腺癌行手术治疗的患者90例。在术前、术后出院前分别采用调查问卷形式收集患者一般资料、自身营养相关症状自我报告等资料,与医院病历系统护理记录中患者营养情况相关内容进行比较,采用Kappa检验分析患者自我报告与护理记录的一致性。结果术前患者自我报告食欲降低、进食量减少、恶心呕吐、肌力减退、体重减轻(连续性)、乏力、腹胀的发生率均明显高于护理记录(P<0.05),仅是否发生腹泻一项与护理记录一致性较好,其他项目如恶心呕吐、乏力、进食量减少、白蛋白是否正常知晓情况等与护理记录一致性均较差;术后出院前患者自我报告的食欲降低、进食量减少、恶心呕吐、肌力减退、体重减轻(连续性)、乏力、腹胀的发生率均明显高于护理记录(P<0.05),与护理记录一致性较差。结论在术前、术后出院前两个时间点,胰腺癌围手术期患者对自身营养相关症状的自我报告与护理记录存在不一致的现象,护理记录存在低估营养相关症状发生率的情况,影响NRS2002营养风险评分及患者主观整体营养相关症状评量表评分准确性,导致不能早期及时发现患者存在营养不良的风险或营养不良,导致营养支持治疗的延迟或延误影响术后康复。故应重视患者自我报告,将自我报告内容作为护理观察、评估的来源。Objective To investigate and explore the consistency between the perioperative self-report of nutrition-related symptoms and nursing records of pancreatic cancer patients.Methods 90 patients with pancreatic cancer who underwent surgical treatment in a tumor hospital from January 2022 to December 2022 were selected by convenient sampling method.Before surgery and before discharge,general information and self-reported nutrition related symptoms of patients were collected via questionnaires,and compared with the content related to patient nutrition in the hospital s medical record system nursing records.The Kappa test was used to analyze the consistency between patient self-report and nursing records.Results The incidence of self-reported decreased appetite,decreased food intake,nausea and vomiting,decreased muscle strength,continuous weight loss,fatigue,and abdominal distension in preoperative patients was significantly higher than that in nursing records(P<0.05).The occurrence of diarrhea was consistent with nursing records,while other items such as nausea and vomiting,fatigue,decreased food intake,and awareness of normal albumin levels,were inconsistent with nursing records.The incidence of self-reported decreased appetite,decreased food intake,nausea and vomiting,decreased muscle strength,continuous weight loss,fatigue,and abdominal distension in patients before discharge after surgery was significantly higher than that in nursing records(P<0.05),and the consistency with nursing records was poor.Conclusions At the two time points—before surgery and before discharge—the self-report of pancreatic cancer patients on their nutrition related symptoms during the perioperative period were inconsistent with the nursing records.The nursing records underestimated the incidence of nutrition related symptoms,which affected the accuracy of NRS2002 nutrition risk assessment and patients subjective global nutrition-related symptoms scale.As a result,the risk of malnutrition in patients could not be identified early and tim

关 键 词：胰腺癌 住院患者 围手术期 营养相关症状 自我报告 护理记录 

分 类 号：R473.73[医药卫生—护理学]