糖尿病酮症酸中毒护理记录书写方法的改进

Practice to improve the quality of nursing records for patients with diabetic ketoacidosis

为了进一步规范护理记录书写内容,提高护理病历书写质量,以糖尿病酮症酸中毒护理病历书写内容为基础,总结以往书写过程中存在的问题,依照《中国2型糖尿病防治指南》酮症酸中毒诊治标准,制定相应的护理措施及病历书写内容,经临床反复实践,护理人员在该病种护理记录书写方面有了很大的提高,记录内容详实、客观,病情描述体现了动态变化,基本达到了护理病历书写规范的要求。

In order to further standardize the writing of nursing records and improve its quality,this paper summarizes the problems in nursing records based on the data of patients with diabetic ketoacidosis. According to the Guideline of Definition, Diagnosis and Classification of Diabetes Mellitus（H）and Its Complications,the standards of nursing care and nursing records for patients with diabetic ketoacidosis were formulated and applied in clinical practice. As a result,the nurses got significant improvement in the writing of nursing records for patients with diabetic ketoacidosis. Compared with before,the nursing records are more objective and informative,could reflect the dynamic changes of illness state and nursing measures,and accord with the standards of nursing records.