呼吸机观察记录卡在病房中的应用探讨

The application of the breathing machine observational records in the wards

目的为使用呼吸机的病人建立统一的呼吸机观察记录卡，降低使用呼吸机产生的意外事故、护理缺陷、护理差错的发生，提高护理服务质量，便于护理管理；密切护患关系，减少护患纠纷。方法将使用呼吸机的病人143例，随机分成实验组和对照组。实验组采用呼吸机观察记录卡，内容包括：气管插管外管长度或气管切开、呼吸机模式、潮气量、吸呼比、呼吸频率、吸人氧气浓度、血氧饱和度、气囊放气时间；护士签名。对照组采用常规护理记录法。结果实验组发生医疗纠纷2例，无1例发生护理差错和护理缺陷；对照组发生护理缺陷16例，医疗纠纷9例，护理差错6例。结论使用呼吸机观察记录卡提供了准确的档案依据，增强了护士的责任心，有效杜绝了护理缺陷和差错的发生，减少了医疗纠纷和投诉；同时简化了护理记录，利于医生和护士观察查阅，值得临床推广应用。

Objective To assist those patients, who are using the respirator, in setting up a unified record card of observation, in order to reduce the accidents, nursing deficiencies and mistakes brought about when using the breathing machine, to improve the quality of nursing service, so as to facilitate the nursing management. Moreover, to strengthen the nurse-patient relationships, avoiding the disputes between the two. btethods Dividing, at random, certain 143 patients, using the respirator, into experi- mental group and control group. For the experimental group, resorting to record card of observation, including the outer tube length of the tracheal spile or cutting into the trachea, respirator mode, tidal air volume, respiratory quotient, respiratory frequency, inhaled oxygen concentration, air bladder deflating time and the signature of the nurse. For the control group, betaking the conventional caring record method.Rtsult8 Nursing deficiencies, 2 medical disputes for the experimental group, hut no nursing mistakes; while 16 nursing deficiencies, 9 medical disputes and 6 nursing mistakes for the control group, respectively. Conclusions The using of record card of observation for respirator provides specific file evidences, which enhance the nurses＇ sense of responsibility, effectively putti^lg an end to the nursing deficiencies and mistakes, decreasing the medical disputes and complaints. At the same times simplifying the nursing record, In favor of doctors and nudes to observe the inspection, it＇s worthy of clinical application.