介入科住院患者疼痛评估护理记录单的设计与应用

The design and application of pain assessment and nursing record sheet for hospitalized patients in the department of interventional radiology

目的通过介入科疼痛评估护理记录单的设计以及住院患者临床实践,规范医护人员对患者疼痛的全面观察与记录,为有效开展疼痛管理提供渠道。方法通过自行设计疼痛评估护理记录单,并应用于2013年3月至2015年5月期间介入科住院患者的疼痛评估的临床实践,全面准确评估记录住院患者疼痛强度及止痛效果。结果疼痛评估护理记录单的设计及应用提高了住院患者疼痛评估记录的准确性和可信度,增强了医护人员整体意识,通过有效的护理措施和用药减轻患者痛苦,为有效开展疼痛管理工作奠定基础。结论在介入患者护理工作中采用明确易行的疼痛评估工具和记录表单,准确评估和记录患者的疼痛情况,使患者得到及时有效的治疗与护理,真正提高介入患者的生活质量。

Objective Through designing the nursing record sheet for pain assessment of hospitalized patients and through clinical practice to formulate standard regulations for medical staff in professionally making comprehensive observation and record of the pain in order to provide effective management measures and methods. Methods A self-designed nursing record sheet for pain assessment was formulated, which was utilized for pain assessment of hospitalized patients, who were admitted to the department of interventional radiology during the period from March 2013 to May 2015. The pain intensity and pain relief effect in the hospitalized patients were comprehensively and accurately assessed and recorded. Results The design and use of nursing record sheet for pain assessment improved the accuracy and reliability of the pain assessment reeords of hospitalized patients, strengthened the team consciousness of medical staff, besides, through effective nursing measures and medication the patient＇s suffering was alleviated. All the above results laid the foundation for effectively carrying out the pain management. Conclusion In making nursing care for patients receiving interventional treatment, the use of simple and clear pain assessment tools and record sheet to evaluate and to record pain extent of patients can ensure the patients to get timely and effective treatment and nursing so that the quality of life of patients receiving interventional treatment can be indeed improved.