急诊重症监护病房个性化危重患者护理计划单的设计与应用效果研究

The design and application of the personalized nursing care plan sheet for critically ill patients in the emergency intensive care unit

目的：探讨个性化危重患者护理计划单在急诊重症监护病房的应用效果。方法根据护理部相关标准设计个性化危重患者护理计划单，内容包括共性及个性化护理问题和护理措施；将2012年1月至2014年9月在我科住院的急诊危重患者116例，按随机数字表法分为观察组和对照组各58例，护士分别采用个性化危重患者护理计划单和医院统一的陈述问题式危重患者护理计划单分别对观察组和对照组患者进行记录和交接，比较2组患者护理质量各项指标、护士对护理计划单的满意度。结果观察组患者的基础护理、专科护理、计划单、病情处置等不合格率和不良事件发生率均明显低于对照组（32.76%比62.07%，χ2=2.98，P ＜0.05；37.93%比67.24%，χ2=2.98，P ＜0.05；29.31%比68.97%，χ2=4.09，P＜0.05；20.69%比53.45%，χ2=3.46，P＜0.05；10.34%比72.41%，χ2=6.60，P＜0.05），差异均有统计学意义，护理质量明显提高。护士对个性化危重患者护理计划单的满意度明显高于医院统一的陈述问题式危重患者护理计划单，P＜0.05。结论使用个性化危重患者护理计划单可防止因病情评估不全或护理计划漏项造成的护理缺陷，从而提高护理质量。

Objective To investigate the effect of the personalized nursing care plan sheet for critically ill patients in the emergency intensive care unit. Methods The personalized nursing care plan sheet including general, personalized nursing issues and related measures was designed according to the standard from the nursing department. A group of 116 critically ill patients were divided into the observational group (58 patients) and control group (58 patients) from January 2012 to September 2014. The personalized nursing care plan sheet were applied for record and hand over in the observational group, while the unified problem statement nursing care plan sheet were used in the control group. The indicators of nursing quality were observed in the two groups and the nurses′satisfaction with the nursing care plan sheets was compared. Results The nursing quality in the observational group was higher than it in the control group with the lower incidence of failure rate in fundamental nursing, professional nursing, plan sheet, disease treatment and adverse event (32.76% vs. 62.07%,37.93% vs. 67.24%,29.31% vs. 68.97%, 20.69% vs. 53.45%, 10.34% vs. 72.41%, the χ2 values were 2.98, 2.98, 4.09, 3.46 and 6.60 respctively, P<0.05). The nurses′satisfaction with the personalized nursing care plan sheet was also higher than the unified problem statement nursing care plan sheet (P<0.05). Conclusion The incidence of nursing defects could be reduced by avoiding the incomplete nursing assessment and omitted nursing plan.