ICU脓毒性休克护理风险矩阵的构建与分析

Construction and analysis on nursing risk matrix for ICU septic shock patients

目的通过构建ICU脓毒性休克护理风险矩阵,量化评估与分析脓毒性休克患者存在的护理风险,为进一步应对和控制脓毒性休克护理风险提供科学的管理依据。方法以风险矩阵理论为指导,运用头脑风暴法、Delphi法和问卷调查法构建ICU脓毒性休克护理风险矩阵图,进一步采用Borda序值法对风险矩阵图中高危风险项进行重要性排序。结果 ICU脓毒性休克护理风险矩阵图显示:23项护理风险中,7项属于I级高危风险(红色区域),16项属于II级中危风险(黄色区域)。7项高危风险的Borda序值结果显示:"未根据患者病情评估是否需要液体复苏"居高危风险首位,"3 h内液体复苏未达到30 mL/kg"和"1h内未使用抗菌药"并列第2位;"未遵医嘱采取药物或机械性方法预防静脉血栓"居第3位;"平均动脉压低于65 mmHg未及时报告医生"和"未每小时监测患者尿量"并列第4位;"血红蛋白低于7.0 g/dL未遵医嘱及时补充红细胞"居高危风险末位。结论 ICU脓毒性休克护理风险矩阵直观、科学地反映了脓毒性休克护理风险防范重点,有助于提高ICU护士对此类患者的风险防范意识,以便提前采取针对性措施保障患者安全。

Objective To quantitatively evaluate and analyze the nursing risk of septic shock patients by constructing the nursing risk matrix of ICU and provide the scientific management basis for further coping with and controlling the nursing risk of septic shock.Methods Under the guidance of risk matrix theory,the nursing risk matrix of ICU septic shock was constructed using the method of brainstorming,Delphi and questionnaire.The importance of high risk in risk matrix was evaluated by the Borda order value method.Results Among the 23 nursing risks,7 risk items were classified as high risk,others were classified as moderate risk of grade.The results of Borda order value showed that:"Do not assess the patient’s need for fluid resuscitation according to the patient’s condition" ranked the first at high risk "Liquid resuscitation did not reach 30 ml/kg within 3 hour" and "No anti-bacterial drugs were used in one hour" were ranked the second at high risk."No drug or mechanical approach to prevention of Venous Thrombosis" ranked the third at High risk."The Mean Arterial Pressure was lower than 65 mmHg without timely reporting to the doctor" and "Not monitoring the patient’s urine volume per hour" were ranked the fourth highest risk."Hemoglobin is lower than 7.0 g/dl not to supplement red blood cell in time" was the last highest risk of high risk.Conclusion The nursing risk matrix of ICU septic shock patients intuitively and scientifically reflects the key points of risk prevention,which might be helpful to improve the risk prevention consciousness of ICU nurses.Thus,measures are taken in advance to ensure the safety of patients.