烧伤重症护理记录单的设计与应用  

The design and application of nursing record sheet for critically burned patients

作　　者：王淑君[1] 耿莉华[1] 宋永音[1] 马红燕[1] 

机构地区：[1]解放军第304医院烧伤整形科,北京100037

出　　处：《护理管理杂志》2004年第3期51-53,共3页Journal of Nursing Administration

摘　　要：目的　完善重症护理记录单 ,记录规范化、标准化 ;观察指标系统化 ,指导不同层次护士工作 ;体现烧伤不同时期病情特点 ;完善记录人员签名负责制 ;减少护理记录工作量。方法　按烧伤分期、护理特点设计表格 ,并与现有表格比较。结果　两种记录单观察指标、记录工作量有明显差异。结论　新的记录单观察较全面、实用和有效 。Objective To improve the charting by nurse in critically burned patient,standardize nursing record of critically burned patient.To observe the systemic parameter and to provide guidance to nurses in various levels.To embody the characterize in the critically burn patients in different stages.To improve the signing and being responsible system and to decrease the working load of nurse.Method The new nursing charting was designed according to the burn stages and nursing emphases characteristic and compared with that of old one in clinical practice.Result The significant differences between two kinds of nursing chartings in items of observation and work load of nurse was observed.Conclusion The new nursing charting is more comprehensive, practical and effective than that of old one.

关 键 词：烧伤 重症 护理记录 

分 类 号：C931.2[经济管理—管理学]