个性化护嘱单的制定与临床运用

Establishment and Clinical Application of Personalized Nursing Order

针对现有护嘱实行过程中的不足,结合临床护理工作量和患者的实际需求,制定符合患者实际需求的个性化护嘱单。方法 :将护嘱分为治疗护理、病情观察和生活护理3部分。治疗护理、病情观察的内容依旧遵医嘱执行,生活护理的内容由护士根据患者实际护理需求,针对科室自身特点设计适合护理人员快速评估患者自理能力的表格式护嘱单,运用日常生活活动评定量表(activities of daily living,ADL)评分法对其生活自理能力进行评估后,确定具体的护理措施。个性化护嘱单的应用,能使患者得到与其实际需要相符合的护理照护,加速患者康复的进程,增加患者满意度,有效分配护理资源。

This paper introduced the establishment and clinical application of personalized nursing order, which was based on clinical nursing workload and aimed at meeting patients＇ requirements. The order included the following three parts, treatment and nursing, observation and daily nursing. In practice, treatment and nursing and observation were conducted with the guidance of medical order while the daily nursing was conducted after the evaluation of patients＇ self-care ability with activities of daily living （ADL）. Personalized nursing order played an important role in promoting patients＇ recovery, which made patients＇ more satisfied.