开发和初步评估一个结构化的叙事护理日志,用于在重症监护病房的有意识患者
Hong-Mei Liu1,2, Jing-Yi Jin1, Jian-Hong Ji2
1School of Nursing and Rehabilitation, Nantong University, Nantong, Jiangsu Province, 226001, People's Republic of China.
Journal of multidisciplinary healthcare
|September 16, 2025
概括
一个新的结构化的叙事护理日志显著减少了患者的焦虑,并改善了在重症监护室 (ICU) 的感知护理. 该日志还减少了护士的文件处理时间,并提高了他们的专业成就.
科学领域:
- 护理科学 护理科学
- 关键设置中的患者护理
- 医疗保健信息学 医疗保健信息学
背景情况:
- 在重症监护室 (ICU) 的有意识的患者需要专门的沟通和文件.
- 现有的护理日志可能无法完全捕捉患者体验的细微差别或支持护士的效率.
- 叙事护理理论为理解和改善患者-提供者沟通提供了一个框架.
研究的目的:
- 根据叙事护理理论开发一个结构化的叙事护理日志.
- 评估本日志在ICU环境中的初步临床有效性.
- 评估对患者焦虑,感知护理,护理时间和护士专业成就的影响.
主要方法:
- 通过文献审查和专家咨询,开发一个结构化的叙事护理日志.
- 准实验性设计,涉及90名有意识的ICU患者.
- 对照组 (空白日志) 与干预组 (结构日志) 的比较.
主要成果:
- 干预组患者报告了显著降低焦虑和更高的感知关怀 (p <0.05).
- 干预组的叙述性护理时间 (25.05分钟) 与对照组 (34.07分钟) (p < 0.05) 相比显著较短.
- 干预组的护士在职业成就方面出现了统计学上显著的增加 (p < 0.05).
结论:
- 结构化的叙事护理日志有效地减少了患者的焦虑,并增强了对护理的感知.
- 它优化了护士花在文档上的护理时间,并增加了护士的专业成就.
- 这种工具有可能改善 ICU 意识患者的护理实践.
相关概念视频
Introduction to Documentation and Reporting
2.9K
Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...
2.9K
Guidelines for Nursing Documentation II
1.6K
Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
1.6K
Guidelines for Nursing Documentation I
1.8K
Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
1.8K
Planning Nursing Care II
3.5K
A nursing care plan can present in two forms: informal and formal. Informal is a care plan for the individual use of the nurse and goals they wish to accomplish during their shift. Informal care plans are not included in the patient chart. A formal nursing care plan is a written or computerized guide that organizes patient care. It is further subdivided into two: standardized and individualized care plans. Standardized care plans are pre-populated care plans for specific patient populations,...
3.5K
Formats for Nursing Documentation
1.9K
Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and ensure comprehensive and accurate patient records. Let's explore each of these formats in detail:
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history,...
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history,...
1.9K
Planning Nursing Care I
5.5K
The planning phase of the nursing process helps nurses set priorities, outline patient-centered goals and expected outcomes, and tailor nursing interventions to align with the aligned care plan. Through the planning phase, the nurse applies critical thinking skills to align and develop interventions according to the patient's needs. It provides continuity of care allowing patients to receive the maximum benefit from treatment. It serves as a pilot plan for allocating individual staff to a...
5.5K

