肝胆外科术后患者基础体征采集-比对-识别隐匿型病情变化的效果观察  

Effect of basic sign collection-comparison-recognition model for occult change after hepatobiliary surgery

作　　者：龚祖华[1] 孙丽[2] 谭璇[2] 张悦[1] 施丹[1] 程娟娟[1] GONG Zu-hua;SUN Li;TAN Xuan;ZHANG Yue;SHI Dan;CHENG Juan-juan(Dept.of Hepatobiliary Surgery,Jinyinhu Campus,Union Hospital,Tongji Medical College,Huazhong University of Science and Technology,Wuhan,430000,China;Dept.of Nursing Administration,Jinyinhu Campus,Union Hospital,Tongji Medical College,Huazhong University of Science and Technology,Wuhan,430000,China)

机构地区：[1]华中科技大学同济医学院附属协和医院金银湖院区肝胆外科,湖北武汉430000 [2]华中科技大学同济医学院附属协和医院金银湖院区护理部,湖北武汉430000

出　　处：《护理学报》2025年第4期74-78,共5页Journal of Nursing(China)

摘　　要：目的 探讨基础体征采集-比对-识别模式在肝胆外科术后心电监护期患者隐匿型病情变化早期识别的效果。方法 选取2024年2—5月符合纳入排除标准的患者269例,按随机数字表法分为对照组136例,给予常规护理;观察组133例,构建基础体征采集-比对-识别模式进行干预。比较2组患者在术后疼痛、发热、恶心呕吐、输液速率异常、腹胀、胸闷气促、出血倾向等病情变化时的差异。结果 观察组患者在术后隐匿型并发症、显性症状识别率方面均优于对照组,差异有统计学意义(P<0.05);观察组患者在术后疼痛评分、恶心呕吐、腹胀、呼吸不畅、输液速率异常评分、出血倾向、呼吸困难等症状程度方面均低于对照组,差异有统计学意义(P<0.05)。结论 结构化基础体征采集-比对-识别系统根据新指南要求进行术前基线体征值监测,通过标准化处理后形成基础血压比对值,作为术后心电监护期患者体征值波动时的参考值,能较好地早期识别隐匿型的病情变化,能有效防控术后患者并发症的发生和发展,对于临床有较好的推荐价值。Objective To observe the effect of basic sign collection-comparison-recognition model for early identification of occult change in patients with postoperative?electrocardiogram monitoring after hepatobiliary surgery.Methods A total of 269 patients who met the criteria from February 2024 to May 2024 were selected,with 136 cases in control group given conventional nursing care,and 133 cases in observation group given nursing care with basic sign collection-comparison-recognition model.Preoperative baseline indexes such as heart rate,blood pressure,etc.were recorded as references for postoperative signs.WPS form calculator with assignment operation was used to identify fluctuations.Once the fluctuations exceeded the range of early warning,structured assessment manual constructed by the evidence-based nursing was used to identify the hazards.The difference between the two groups of patients in terms of the incidence of postoperative pain,fever,nausea and vomiting,abnormal infusion rate,abdominal distension,chest tightness and shortness of breath,and bleeding tendency was compared.Results The identification rate of occult complications and overt symptoms in the observation group was higher than that in the control group,and the difference was statistically significant(P<0.05).Patients in the observation group performed better in terms of postoperative pain score,nausea and vomiting,abdominal distension,dyspnea,infusion rate abnormality,bleeding tendency and difficulty in breathing(P<0.05),showing statistical significance.Conclusion Basic sign collection-comparison-recognition mode is effective for recognizing the occult changes of vital signs after hepatobiliary surgery,and can effectively prevent and control the occurrence and development of complications in postoperative patients.

关 键 词：隐匿型病情变化 基础体征 术后护理 肝胆外科 

分 类 号：R473.6[医药卫生—护理学]