摘要
目的基于儿童早期预警评分制订路径式护理记录模板,并探讨其在危重呼吸系统疾病住院患儿病情观察中的应用效果。方法选取安徽省某三级甲等儿童专科医院试点病区2017年1月—9月呼吸系统疾病住院患儿110例为试验组,2016年1月—9月呼吸系统疾病住院患儿110例为对照组,试验组临床应用儿童早期预警评分评估病情并采用护理记录模板记录,对照组常规进行病情观察和护理记录,比较两组患儿病重时数、心电监护时数、吸氧时数、住院天数、住院费用、转入儿童重症监护室例数和护理记录缺陷等指标。结果试验组住院费用、转入儿童重症监护室例数低于对照组(P<0.05);护理记录缺陷明显减少。访谈护士结果显示,该模板可以减少单例患儿单次护理记录书写时间10~15 min。结论使用儿童早期预警评分护理记录模板记录患儿病情,可以提高护理记录书写质量,减少护士书写护理记录时间,增加护士直接评估病情和进行护理干预的时间,减少呼吸系统疾病患儿非计划儿童重症监护病房入住率,降低住院费用。
Objective To explore the efficacy of path-type nursing record template based on early warning score of children in hospitalized children with critical respiratory diseases. Methods We recruited 110 hospitalized children with respiratory diseases from January to September 2017 as the experimental group,and 110 during the same period of time in 2016 as the control group. The Pediatric Early Warning Score was used in the experimental group to assess the condition and the nursing record template was used,and the control group received conventional observation and nursing records. Duration of critical period,hours of monitoring,hours of oxygen inhalation ,length of hospital stay ,expenditure of hospitalization, and number of patients transferred to pediatric intensive care unit,and nursing record defects were compared between groups. Results Compared with the control group,expenditure of hospitalization and number of patients transferred to pediatric intensive care unit were significantly reduced（P〈0.05） in the experimental group,and nursing record defects were reduced. Results from interviews with nurses confirmed that the designed template was able to reduce documentation time for 10-15 minutes for a single patient. Conclusion Pediatric Early Warning Score nursing record template can improve quality of nursing record writing and reduce documentation time for clinical nurses,increase time for disease assessment and intervention,reduce the rate of un- planned transfer into pediatric intensive care unit ,and reduce expenditure of hospitalization.
作者
赵燕
黄丽华
尚启云
孙贻霞
段明霞
许蕾
王驰
ZHAO Yan;HUANG Lihua;SHANG Qiyun;SUN Yixia;DUAN Mingxia;XU Lei;WANG Chi
出处
《中华护理杂志》
CSCD
北大核心
2018年第6期679-683,共5页
Chinese Journal of Nursing
基金
2017年安徽省卫生计生委科研计划项目(2017ek011)
关键词
儿科
呼吸系统疾病
护理记录
儿童早期预警评分
Pediatrics
Respiratory System Diseases
Nursing Records
Pediatric Early Warning Score
