护理风险综合评估信息系统在普外科的应用与效果

Application and Effect of Nursing Risk Comprehensive Evaluation Information System in General Surgery

目的探讨护理风险综合评估信息系统的在普外科临床的应用与效果。方法随机选取在2015年1月—2016年12月之间于该院治疗的1 107例患者,护理风险综合评估信息系统包括国际通用的新版压疮Branden评分,跌倒评分系统,生命体征加上十大系统疾病症状评分系统(十大系统为神经精神系统、呼吸系统、消化系统、循环系统、运动系统、内分泌系统、免疫系统、泌尿系统、生殖系统及妇产系统、血液系统、其他系统)3个模块。由责任护士或值班护士对患者进行全面、动态评估并向医生进行风险告知及签字,且风险内容体现于病程记录中。结果应用前后的满意度分别为94.9%、96.8%,应用前后不良事件的发生率分别为1.45%,0.76%,应用后护士掌握患者病情程度、不良事件发生率以及护理满意度明显优于应用前,应用前后比较差异有统计学意义(P<0.05)。结论应用护理风险综合评估信息系统可有效提高护士对患者病情的掌握程度,使护理不良事件发生率下降,值得推广应用。

Objective This paper tries to explore the clinical application and effect of general assessment of nursing risk in general surgery. Methods 1107 cases were randomly selected from January 2015 to December 2016 in this hospital, and the nursing information system risk evaluation including the international version of pressure Branden score, fall score system,vital signs plus ten system disease symptom scoring system（including the neuropsychiatric system, respiratory system, digestive system, circulatory system, motor system, the endocrine system, the immune system, the urinary system, the reproductive system and the maternity system, the blood system, and other systems）. The nurses on responsibility or nurses on duty carried out a comprehensive, dynamic assessment and reported risk to doctors and signed their names, and the risk content was reflected in the course of the record. Results The satisfaction degree before and after the application were94.9% and 96.8%, the incidence of adverse events before and after the application were 1.45% and 0.76%, the severity and incidence of adverse events and nursing satisfaction after the application were significantly better than before the application, and the difference was statistically significant before and after the application（P〈0.05）. Conclusion The application of nursing risk comprehensive assessment information system can effectively improve the nurses＇ mastering of the degree of disease, so that the incidence of adverse care events can be decreased, therefore it is worth promoting and application.