心胸外科监护室危重患者床尾病情记录单使用效果评价

摘要

目的：及时准确了解心胸外科危重患者的病情动态，提高护理和交接班质量。方法：设计使用包含交接班主要内容的床尾病情记录单，将全年心胸外科危重患者随机分成试验组(使用床尾病情记录单)和对照组(常规交接班)，以查资料时间、交接班时间和交班内容完整性三项指标进行评判，结果进行统计学处理。结果：试验组查阅资料和交接班所需要的时间比对照组明显短，交班内容完整性明显优于对照组，差异均有统计学意义(P<0.01)，护理人员间因工作年限、职称和学历不同对交班内容完整性影响比较差异均无统计学意义(P>0.05)。结论：使用心胸外科监护室危重患者床尾病情记录单可以有效缩短当班护士查资料和交接班时间，提高交班内容的完整性，改进工作效率和质量。%Objective:To understand the dynamic information of critical patients correctly and timely in the Cardiothoracic Surgical,and improve the quality of nursing and succession.Method:Random allocation was taken to divide the critical patients in Cardiothoracic Surgery into two groups,using the nursing sheet in the end of the bed as the experimental group,and the routine succession as the control.Statistical analysis was performed to find the difference between the two groups in the time for checking information,the time for nurse’s shifting and content integrity.Result:The experimental group spent less time than the control on the time for checking information,the time for nurse’s shifting,and the content integrity were better than the control group(P<0.01).There was no significant difference between different nursing seniority in the experimental group in content integrity,and also in different professional titles and education(P>0.05). Conclusion:Using nursing sheet in the end of the bed of critical patients in Cardiothoracic Surgery care unit can effectively shorten the nurses on duty to check the record data and the time for nurse’s shifting,improve the integrity of its succession,work efficiency and quality.