入院患者护理评估单的设计与应用

Design and application of nursing evaluation checklist of inpatients

目的加强对患者护理风险的评估，提高对患者的护理管理及护理质量。方法设计并客观、合理、简要、适用于住院患者护理评估的评估单，包括入院患者护理评估单、住院患者跌倒风险评估表、人院患者压疮评估量表及患者安全告知书，对应用前后住院患者护理问题发生率进行对比。结果使用住院患者护理评估单前，住院患者护理问题发生率为0．610％，使用后为0．078％，两组比较差异有统计学意义（x2=8．985，P〈0．01）。结论应用住院患者护理评估单发挥了对患者健康评估的指导作用，强化了护士的护理安全意识，有效降低住院患者护理问题的发生率；评估单内容具有个体化、科学性和实用性，值得临床推广。

Objective To strengthen the evaluation of nursing risks of inpatients and to improve the management of inpatients and nursing quality. Methods We designed nursing evaluation checklist which was objective, rational, brief and suitable for the inpatients, including nursing evaluation checklist of admission, falling risk evaluation checklist of inpatients, decubitus evaluation checklist of inpatients and safety notice for patients. Occurrences of nursing incidents before and after the application were compared. Results Occurrence of nursing incidents was 0.610% before the application and 0.078% after the application. The difference was statistically significant（ X2 = 8. 985, P 〈 0.01 ）. Conclusions Application of nursing evaluation checklist of inpatients guides the health assessment of patients, enhances the nursing safety awareness of nurses and effectively reduces the occurrence of the nursing incidents. Nursing evaluation checklist has the advantages of individuation, scientificalness and practicality, and should be extended in clinical application.