摘要
随机抽取我科１９９７年３月—１１月１００份整体护理病历，对其中８１４个护理问题对应的４６５５条护理措施进行分析，结果陈述不清楚、欠条理的２６５条（５．７％），措施可行性差１４７条（３．２％），护理措施与护理问题不符１０７条（２．３％），措施缺乏科学依据８８条（１．９％），护理措施与医疗措施混淆２０１条（４．３％）。提出：正确掌握护理措施意义及范畴，遵循护理措施与护理问题一致的原则，从实际出发，制定切实可行的有效的护理措施。
cases holistic nursing care medical records were taken out randomly dated from Mar.to Nov.of 1997.And 4 655 pieces of nursing care measures of 814 issues were analysed.Results showed that 265 pieces(5.7%) statements were unclear and poor-organized;147 pieces(3.2%)of measures were with poor feasibility;107 pieces(2.3%) of measures did not tally with issues;88 pieces (1.9%)of measures lacked of scientific basis;and 201 pieces(4.3%)mixed up nursing care measures with medical measures.Proposed that one grasp the meaning and category of nursing care correctly,follow the principle of nursing care measures being consistent with nursing issues,and proceed from actual conditions,make out feasible and effective nursing care measures.
关键词
整体护理
护理措施
护理病历
Systematic holistic nursing careNursing care measuresNursing medical record
