创伤患者就诊时护理评估存在的问题及护理对策

[摘要] Abstract：ABSTRACT: Objective To explore the problems of nursing assessment and nursing countermeasures in trauma patients on hospital visit. Methods A total of 400 medical records of trauma patients from October 2012 to October 2013 were randomly checked. The problems of nursing assessment in these medical records were inspected, and the reason and nursing countermeasures were analyzed and summarized. Results In the 400 medical records of trauma patients, 41 medical records were wrong with incomplete items (10.25%), 36 medical records with protracted nursing assessment (9.00%), 28 medical records with inconformity of the patients′ conditions and assessment contents (7.00%), 45 medical records with total copy of doctor examination results (11.25%), 38 medical records with lack of vital signs (9.50%), 26 medical records with incomplete or inaccurate records of history of diseases (6.5%), 57 medical records with ignore of other diseases (14.25%), 63 medical records with alter, modify or scribbled assessment record (15.75%). The causes of problems of medical records were various, including inadequate understanding of nursing assessment, subjective assessment, lack of good communication skills, unreasonable nursing knowledge structure, inadequate number of nursing staffs, the wrong filling position, and unstable mental status of nurses and lack of systematic nursing assessment skills. After implementation of targeted nursing countermeasures, the number of medical records with the eight problems above significantly reduced (P＜0.05). Conclusion There are a lot of problems in nursing assessment of trauma patients on hospital visits, and implementation of targeted nursing countermeasures can significantly avoid the occurrence of wrong assessment.

[学科分类] 护理学

[关键词] 创伤;护理评估;问题;护理对策