表格加焦点式护理记录单在颅脑损伤中的设计与应用

The designing and clinical application of score table and focus nursing sheet in brain trauma diseases

目的通过对脑外伤表格加焦点式护理记录单的设计与临床应用，指导神经外科医护人员专业化、个体化观察病情，进一步优化细化护理内容，更好地保证脑外伤患者的医疗护理安全。方法根据疾病种类和症状学特点设计脑外伤表格加焦点式护理记录单，与原运行的病情观察护理记录单对照，选择护理记录时间、护理记录缺陷发生率、护士专业知识考试结果、医生满意度作为效果评定指标。结果临床应用130例患者，经效果评价，临床应用效果优于原运行护理记录单。结论表格加焦点式护理记录单更能科学便捷地记录脑外伤病情及治疗护理过程，突出个体化、专业化的护理理念，值得推广。

Objective By the designing and clinical application of score table and focus nursing sheet to brain trauma patients, paramedics can observe state of illness individually, optimize the nursing care in a fur- ther performance, and ensure the security of brain tramna patients more profitably. Methods To design the score table and focus nursing sheet according to the disease species and symptoms, contrast to the previous nurse observing table in noting time, error rate, exam results and surgeon satisfaction degree. Results By evaluating 130 cases in this test, the score table and focus nursing sheet were superior to the previous nurse observing table. Conclusions With the score table and focus nursing sheet,nurses can observe the ill- ness and note the progress more scientifically and conveniently, the concept of individuation and specializa- tion are worthy of recommending.