应用胸外科术后呼吸道观察与护理记录表实施专科护理的临床实践

The clinical application of postoperative respiratory tract observation and nursing care record form in thoracic surgery patients

目的:制定并应用自行设计的胸外科呼吸道观察与护理记录表对患者实施专科护理,并进行效果评价。方法:在分析既往出现呼吸道并发症的病例的基础上,明确影响呼吸道护理质量的因素,完善人员培训及健康宣教,制定并应用胸外科呼吸道观察与护理记录表,比较应用该表前后,术后肺不张的发生情况。结果 :应用前肺不张的发生率为3.93%,应用后的发生率为0.49%,较应用前有所降低,且差异有统计学意义(P<0.05)。结论:胸外科呼吸道观察与护理记录表可以起到规范专科护理并促进信息沟通的作用,提高了护理质量。

Objective：To evaluate the effect of postoperative respiratory tract observation and nursing care record form in thoracic surgery patients. Methods：Based on the analysis of the previous cases of respiratory complications, the authors clariifed the inlfuencing factors of respiratory tract nursing care quality. Then they improved staff training and patients＇ health education, and developed the respiratory tract observation sheet to monitor patients＇ respiratory tract condition. The incidence of pulmonary atelectasis after surgery was compared between before and after the application of the sheet. Results：After using the sheet to care patients, the incidence of pulmonary atelectasis declined from 3.93%to 0.49%（P〈0.05）. Conclusion：The thoracic surgery breathing tract observation and nursing care record form could standard speciifc thoracic surgery nursing and improve information communication among nurses, physicians, patients and their family members. Therefore, it could improve nursing care quality.