腹部损伤患者护理评估常见问题及护理对策

Frequently asked questions of nursing evaluation of abdominal injury patients and its nursing countermeasures

目的探究腹部损伤患者护理评估常见问题及护理对策。方法按照随机数字表法抽查400份腹部损伤患者进行分析,记录病历中护理评估表存在的问题,总结解决护理评估问题的相应对策。结果随机抽取的400份患者病历,护理评估问题主要存在评估内容不符、与医生评估相同、护理评估不全面、缺乏疾病综合判断能力、评估时机不恰当、忽略其他疾病、擅自修改记录及评估书写不规范等8大问题;护理评估出现问题主要分为思想不够重视、主观评估、沟通技巧欠缺、护士知识结构不合理、人数不足、心理不稳定及缺乏系统护理评估体系等7个方面;实施护理对策后,出现护理问题的病历数和比例均改进前显著降低,差异具有统计学意义(P<0.05)。结论实施针对性护理对策,能够显著降低出现护理评估问题的病例数,对患者的治疗、预后均具有重要临床意义。

Objective To explore common problems of nursing evaluation of abdominal injury patients and nursing countermeasures. Methods A total of 400 patients with abdominal injury were analyzed according to random number table method. The problems of nursing assessment were recorded and nursing countermeasures were summarized. Results In 400 randomly selected medical records,nursing assessment problems mainly included unconformity to assessment content,the same assessment with doctors,uncomprehensive nursing evaluation,lack of judgment for disease,inappropriate evaluation time,ignoring other diseases,unauthorized modification records and not standardized writing. The problems of nursing assessment were lack of enough attention,subjective assessment,lack of communication skills,irrational nursing knowledge structure,insufficient nursing staff,mental instability and lack of nursing assessment system. After nursing,front and rear countermeasure,the number of medical records related to nursing problems and proportion were significantly lower than nursing before,and the differences were statistically significant（ P〈0. 05）. Conclusion Targeted nursing strategies can significantly reduce the number of patients with nursing assessment problems and it is of great clinical significance for prognosis and treatment for patients.