压疮评估对肿瘤骨转移患者压疮预防的效果评价

Efficacy Evaluation of Press Sore Prevention in Patients with Metastasis Tumor Bone

目的：为肿瘤骨转移患者压疮预防的方法进行总结评价以达到对临床肿瘤压疮进行指导。方法：采用改良后的诺顿评估表（信度0．80，效度0．84）作为压疮易患患者评估工具。评估内容包括患者年龄、身体状况、意识、活动能力、运动受限情况、疼痛、皮肤情况、大小便失禁、饮食、进食能力、口腔情况、牙齿及患者血色素、蛋白等资料。评估时间从患者人院开始，对30例肿瘤全身多处骨转移患者进行评估，有预见性、计划性，针对性及个体化对患者制订护理计划及措施，并督促实施，对效果进行评价分析。结果：≤25分高危险性患者（难以避免）发生率50％，26～29分中度危险性患者（可避免）发生率0，≥30分低危险性患者发生率14．2％。效果评价：压疮预防评估对肿瘤骨转移患者压疮的预防是有效的，压疮评估有助于规范护理行为和护理管理；通过分析找出护理过程中的薄弱环节，以利于指导临床工作。

Objective：To summarize and evaluate the preventative method of pressure sore for the patients with osseous metastasis from tumor and provide guidance for pressure sore of clinical tumor. Methods：Taking Nuodun evaluation sheet improved （reliability 0.80,validity O. 84） as evaluation- tools for the patients who get sick easily. The content as sessed includes patients ＇ age, physical status, consciousness, locomotor activity, limitation of movement, pain, skin, urina ry and fecal incontinence,food and drink,the ability of food intake,the condition of oral cavity,teeth,blood pigment,pro- tein and so on. Evaluate 30 patients with osseous metastasis from tumor all over the body start at the admission,formu late nursing plan and measurement predicted, designed, directly and individually, supervise and urge to enforce, evaluate and analyze the effectiveness. Results：The incidence rate is 50 % of high risk patients 425 （can＇t avoid）, 0 % of poor risk patients 26-29 （can avoid）, 14.2% of low risk patients. Evaluation of effectiveness：The assessment of pressure sore prevention is effective for the patients with osseous metastasis from tumor and conduce to norm nursing behavior and nursing supervision,and help nurse to find out weak link in nursing process through analysis,and profit to guide clinical work.