病情評估表在神經內科患者分級護理中的應用效果

宋正新+王敏

[摘要]目的 觀察應用自制病情評估表對我院神經內科患者實施分級護理的效果。方法 選擇2016年6～12月我院收治的203例患者作為研究對象，依據入科時間先后順序將患者分為觀察組102例及對照組101例。對照組患者由護理人員按照Barthel指數評定表給予評分，醫生以該評分為主要依據評定護理等級。觀察組在對照組基礎上，醫生按照自制病情評估表對患者進行神志、年齡、體溫、心率、呼吸、血壓、血氧飽和度、血糖、潛在并發癥的監測，根據評分標準將患者病情分為輕、中、重、危四個級別，據此再結合Barthel指數評定等級下達護理等級醫囑。比較兩組患者的護理等級符合率、基礎護理合格率及患者滿意度調查結果。結果 觀察組患者的護理等級符合率、基礎護理合格率及患者滿意度均優于對照組，差異均有統計學意義（P<0.05）。結論 應用自制病情評估表能使分級護理的判定更細則化、規范化，提高護理工作質量及患者滿意度。

[關鍵詞]病情評估表；Barthel指數評定表；分級護理

[中圖分類號] R473.71 [文獻標識碼] A [文章編號] 1674-4721（2017）08（c）-0173-03

[Abstract]Objective To observe the effect of grading nursing on the patients in neurology department of our hospital with self-made disease assessment scale.Methods From June to December 2016，203 patients received treatment in our hospital were selected as the research objects，and divided into observation group （102 cases） and control group （101 cases） according to the chronological order of admission time.The patients in the control group were given a score according to the Barthel index evaluation scale by nurses，and the doctors rated the nursing grade on the basis of the score.The doctors in the observation group according to self-made disease assessment scale to assess the condition monitoring of consciousness，age，body temperature，heart rate，respiration，blood pressure，oxygen saturation，blood glucose，and the potential complications of patients based on the control group.The patients were divided into four levels of light，medium，heavy and dangerous level according to the scoring criteria.Based on the results of this level judgment and combination the score of Barthel index evaluation，the doctors issued the level of nursing orders and gave a nursing order.The results between the two groups of patients with nursing grade compliance rate，basic nursing qualification rate and patient satisfaction survey were compared.Results The nursing grade compliance rate，basic nursing qualification rate and patient satisfaction were all better than the control group，and the differences were statistically significant（P<0.05）.Conclusion Application of the self-made disease assessment scale can make the grading nursing more detailed and standardized，also can improve the nursing quality and patients satisfaction.

[Key words]Disease assessment scale；Barthel index evaluation scale；Grading nursing

神經內科多收治出血性或缺血性腦血管病患者，該類疾病在我國的發病率逐日增高，發病后病情重，患者的各項神經功能均會受到不同程度的損害，會嚴重影響患者入院后的自理能力，需及時給予治療護理。目前，我國的等級護理主要依據醫生對患者病情的判斷和護士對患者自理能力的評估，由醫生下達等級護理的醫囑，依次分為特級、一級、二級、三級，共四個護理級別[1]。但在實施過程中，患者病情的嚴重程度判斷是根據醫生的主觀判斷得到的，缺乏科學規范的細則依據，常出現醫囑下達的護理等級與患者的護理需求不相符合的現象[2-3]。……