结构化护理风险评估在神经重症监护病房护理中的应用

Application of Structured Nursing Risk Assessment in Neuro-intensive Care Unit Nursing

目的 探讨在神经重症监护室中结构化护理风险评估单的应用效果,以期通过精简护理记录起到提高护理质量的作用。方法 随机选取某三甲医院神经重症监护病房2020年1月1日-2020年6月30日收治的100例患者为对照组,2020年7月1日-2020年12月31日收治的100例患者护理文书为观察组。对照组采用常规风险评估方法,并使用半结构化重症护理记录单的书写,观察组使用结构化护理风险评估与记录方式,两组在书写时间、书写质量、护士使用满意度及质量控制等方面进行比较。结果 观察组入院评估平均用时(176.60±37.18)秒、出院评估平均用时(167.51±33.14)秒、交接班记录平均用时(122.73±40.44)秒、各类风险评估平均用时(149.15±36.31)秒少于对照组(235.40±44.95、213.80±23.09、220.55±44.89、195.24±34.44)秒,差异具有统计学意义,P<0.05;观察组体温单得分(33.44±1.51)分,各类评估单得分(24.13±1.99)分,重症护理记录单得分(38.89±1.03)分高于对照组(30.71±2.21、21.65±2.07、37.55±1.43)分,两组比较差异具有统计学意义,P<0.05;观察组护士对应用结构化护理风险评估与记录系统总体满意度为95.73%,各条目均分为(4.79±0.41)分。结论 结构化护理风险评估与记录方法在神经重症监护病房应用具有方便、快捷、高效的特点,可有效提高护士工作效率和工作质量。

Objectives To explore the application effect of structured nursing risk assessment sheet in neuro-intensive care unit,so as to improve the quality of nursing by simplifying nursing records.Methods 100patients admitted to the neurological intensive care unit of a grade A hospital from January 1st,2020 to June 30th,2020 were randomly selected as the control group,and 100 patients admitted from July 1st,2020 to December 31st,2020 were selected as the observation group.The control group used conventional risk assessment methods and semi-structured critical care record sheet writing,while the observation group used structured nursing risk assessment and record writing methods.The two groups were compared in writing time,writing quality,nurses’ satisfaction and quality control.Results The average time of admission evaluation(176.60±37.18) seconds,discharge evaluation(167.51±33.14) seconds,the average time of shift record(122.73±40.44) seconds,the average time of all kinds of risk evaluation(149.15±36.31) seconds was less than that of the control group(235.40±44.95) seconds,(213.80±23.09,220.55±44.89,195.24±34.44) seconds,the difference was statistically significant,P<0.05;The scores of body temperature sheet(33.44±1.51),evaluation sheet(24.13±1.99) and critical care record sheet(38.89±1.03) in the observation group were higher than those in the control group(30.71±2.21,21.65±2.07,37.55±1.43),and the differences were statistically significant,P<0.05;The overall satisfaction of nurses in the observation group with the application of structured nursing risk assessment and recording system was 95.73%,and each item was divided into(4.79±0.41) points.Conclusions The application of structured nursing risk assessment and recording method in neuro-intensive care unit was convenient,fast and efficient,which could effectively improve the work efficiency and quality of nurses.