CAJ | 학술논문

目的探讨改进三测单记录创伤患者疼痛信息,在简化护士记录及疼痛管理中的应用效果.方法将本科室的两个病区设立成对照组与研究组,随机收住患者于两组.对照组疼痛记录方法沿用传统护理记录单,用文字形式记录疼痛信息;研究组则用改进三测单,增加疼痛评分一栏,并用曲线形式记录疼痛信息.比较两组患者对疼痛控制满意度.住院期间疼痛控制效果,护士记录时间.结果研究组患者对疼痛控制满意度高于对照组(P＜0.05);住院期间疼痛控制显著优于对照组(P＜0.001);用改进三测单记录所需时问比传统记录时间缩短1/3.结论将疼痛强度以曲线的形式记录在三测单上,能使医护人员直观、动态的了解患者疼痛强度及疼痛变化趋势,使患者的疼痛得到及时、有效的处理,提高患者对疼痛控制的满意度,节约护士记录时间,适合在手术科室推广使用.
목적 탐토개진삼측단기록창상환자동통신식,재간화호사기록급동통관리중적응용효과.방법 장본과실적량개병구설립성대조조여연구조,수궤수주환자우량조.대조조동통기록방법연용전통호리기록단,용문자형식기록동통신식;연구조칙용개진삼측단,증가동통평분일란,병용곡선형식기록동통신식.비교량조환자대동통공제만의도.주원기간동통공제효과,호사기록시간.결과 연구조환자대동통공제만의도고우대조조(P＜0.05);주원기간동통공제현저우우대조조(P＜0.001);용개진삼측단기록소수시문비전통기록시간축단1/3.결론 장동통강도이곡선적형식기록재삼측단상,능사의호인원직관、동태적료해환자동통강도급동통변화추세,사환자적동통득도급시、유효적처리,제고환자대동통공제적만의도,절약호사기록시간,괄합재수술과실추엄사용.
Objective To investigate the effect of improved three-item nursing recording sheet on simplifying nursing record and pain management in trauma ward. Methods The patients involved two wards in our department were divided into control group and study group. Control group was adopted conventional nursing recording sheet to record pain information with words. In study group, the improved three - item nursing recording sheet added pain scoring column was used to record pain information through the curve form. The effect, satisfaction of pain control and nursing record costing time were compared between two groups. Results Satisfaction of patients in study group was better than control group ( P＜0.05 ) ; The effect of pain control in study group wassignificantly better than control group (P＜0.001 ) ; The time of nurse recording was reduced one-third. Conclusions The improved recording sheet can make doctors and nurses visually, dynamically know pain intensity and trends, make patients receive timely and effective treatment, promote patient satisfaction with pain control, save recording time. This method is suitable for the surgical department.