儿童早期预警评分在重症肺炎路径式电子护理记录中的临床应用

Clinical application of children early warning score in electronic nursing record of severe pneumonia

目的探究重症肺炎路径式电子护理记录中采用儿童早期预警评分(PEWS)的临床应用研究。方法选择60例重症肺炎住院患儿作为本次研究对象,随机抽取2019年1月1日-12月31日未采用PEWS护理记录模板的30例患儿为对照组与2020年1月1日-12月31日采用PEWS护理记录模板的30例患儿为观察组,对比两组护士护理干预时间与评估病情时间、患儿非计划入监护室率、护士满意度。结果观察组护理干预时间较对照组显著提升,评估病情时间显著降低,组间对比差异显著(P<0.05);观察组护士满意度得到显著提升,与对照组对比差异显著(P<0.05);观察组患儿的非计划入监护室率显著降低,组间对比差异显著(P<0.05)。结论PEWS评分建立以分值为导向的电子护理记录方式可进一步缩短书写记录时间,增加护士直接评估病情和进行护理干预时间,提高护士病情观察能力及护理质量,在此基础上提升记录的准确性,在避免记录缺陷的基础上,降低患儿的非计划入监护室率,提高护理文书的及时性、客观性,缩短书写护理记录时间,减轻护士压力,临床应用效果显著。

Objective To explore the clinical application of pews in the electronic nursing record of severe pneumonia.Methods Sixty hospitalized children with severe pneumonia were selected as the object of this study,and 30 patients who did not use the PEWS nursing record template from January 1 to December 31,2019 were randomly selected as the control group and January 1 to December 31,2020,who were treated with PEWS care the 30 cases in the record template were the observation group.The nursing intervention time and the evaluation time of the two groups of nurses were compared,the rate of unplanned admission of children to the intensive care unit,and the satisfaction of the nurses.Results The nursing intervention time of the observation group was significantly longer than that of the control group,the time to assess the condition was significantly reduced,and the comparison between the groups was significantly different(P<0.05);the satisfaction of nurses in the observation group was significantly improved,and the difference was significant ompared with the control group(P<0.05);The unplanned admission rate of children in the group was significantly reduced,and the difference between the groups was significant(P<0.05).Conclusion The establishment of pews score oriented electronic nursing record can further shorten the time of writing record,increase the time for nurses to directly assess the condition and carry out nursing intervention,improve the ability of nurses to observe the condition and the quality of nursing,improve the accuracy of the record on this basis,reduce the unplanned admission rate of children into the intensive care unit on the basis of avoiding record defects,and improve the quality of nursing The timeliness and objectivity of the document can shorten the time of writing nursing records,reduce the pressure of nurses,and the clinical application effect is remarkable.