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基于信息化平台的急诊危重症患者护理核查单的设计及应用

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目的 探讨基于信息化平台的急诊危重症患者护理核查单的设计及应用效果.方法 基于院内信息化平台,设计急诊危重症患者护理核查单.采用前瞻性类实验性研究方法,观察危重症患者护理核查单应用前后护理交接班的遗漏率、临床护理效果和护理质量.结果 应用急诊危重症患者护理核查单后,护士在管路、通气方式、留置针、用药、皮肤和约束方面的交接班遗漏率显著低于应用前(均P<0.05);临床护理效果和护理质量较核查单应用前显著提升(均P<0.05).结论 基于信息化平台的急诊危重症患者护理核查单的应用可减少护士交接班的遗漏内容,提高护理记录准确性,并缩短书写时长,提高护理质量.
Design and application of information platform based nursing checklist for critically ill patients in the emergency department
Objective To design and explore the application effect of the information platform based nursing checklist for critically ill patients in the emergency department.Methods Based on the information platform in the hospital,a nursing checklist for critically ill patients in the emergency department was designed.Using the prospective quasi-experimental research design,the omission rate,clinical nursing effect and nursing quality of nursing handover before and after the application of the nursing checklist for critically ill patients were observed.Re-sults After the use of the nursing checklist,rates of nurses'omission in checking of intravenous lines,mode of ventilation,indwelling catheters,medications,skin and restraints were significantly lower than those before the use of the checklist(all P<0.05).The clinical nursing effect and nursing quality were significantly improved compared with those before the application of the checklist(all P<0.05).Conclusion The application of the information platform based nursing checklist for critically ill patients in the emergency department can re-duce the missing contents of nurses'shift handover,improve the accuracy of nursing records,shorten the writing time of nursing records,and improve nursing quality.

emergency roomcritical illnessinformatizationchecklistshift handoverintravenous linesmode of ven-tilationnursing safety

杜岳、薛宁宁、陈征

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首都医科大学附属北京天坛医院急诊科(北京,100070)

急诊科 危重症 信息化 核查单 交接班 管路 通气方式 护理安全

2024

护理学杂志
华中科技大学同济医学院

护理学杂志

CSTPCD北大核心
影响因子:2.062
ISSN:1001-4152
年,卷(期):2024.39(4)
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