重症监护病房特护记录单的改进

Improvement and Clinical Application of Special Nursing Records in ICU

目的完善改进特护记录单,记录规范化、系统化,记录观察指标动态反应病情变化。减少护士书写护理记录工作量。方法根据临床护理工作的实际情况,研究改进由生命体征记录单、出入量记录单、病情护理记录单、机械通气监护记录单组成的特护记录单。并与其他监护室手写特护记录单相对比。结果2种特护记录单在记录用时、记录观察指标信息量、整洁程度上均有统计学意义(p<0.05)。结论改进后特护记录单临床应用记录观察指标更详细、信息量更大、护士记录用时比手写特护记录单少,并且为重症监护治疗病房的进一步建立信息集成化管理奠定基础。

Objective To perfect the special nursing records, make the records standardized and systematic, and reduce the workload of nurse in nursing records, Melhods According to the practical work in clinical nursing, we studied and ameliorated the special nursing records consisting of vital signs records, intake and output records, disease nursing records and mechanical ventilation monitoring records, and compared it with handwritten special nursing records in other ICU. Results There were significant difference between these two special nursing records in time for recording, information reflected by observational indexes and the orderhness （P 〈 0.05）. Conclusion The ameliorated special nursing records, with more detailed observational indexes and more information, takes less time for nurse to record than the handwritten one, which provides a basis for the further establishment of information integration in ICU.