患者报告的不适和中静脉导管手术后术后护理的临床文档之间的差异:一项前性描述性研究
Maria Lithner1, Adina Noghi2, Thomas Kander3,4
1Department of Health Sciences Lund University Lund Sweden.
Health science reports
|December 19, 2025
概括
护士对患者中枢静脉导管不适的经验显著没有充分记录. 改进文档实践对于加强以患者为中心的术后护理和尽量减少导管使用至关重要.
科学领域:
- 医学和外科护理 医学和外科护理
- 患者安全 患者安全
- 医疗保健文档 医疗保健文档
背景情况:
- 中枢静脉导管 (CVC) 对腹部手术患者至关重要,但存在感染风险.
- 插入部位的CVC感染的早期迹象经常被忽视.
- 这项研究旨在比较患者报告的CVC体验与护理文档.
研究的目的:
- 评估患者报告的不适和与中央静脉导管相关的记录症状之间的差异.
- 确定在腹部手术后的护理文档和患者护理方面的改进领域.
主要方法:
- 一个定性观察性研究,涉及简短的患者访谈.
- 对电子健康记录的审查,以记录CVC相关的症状和护理.
主要成果:
- 包括106名患者;103人患有内静脉心血管疾病,平均停留时间为10天.
- 没有发生与导管相关的感染,但注意到了潜在的风险.
- 37名患者报告显著的不适 (疼痛,运动受限),但只有3例被记录.
结论:
- 对患者的症状和需求进行系统的记录对于以患者为中心的术后护理至关重要.
- 标准化的电子健康记录模板应包括CVC症状文档.
- 需要明确的指导方针来优化CVC保留或移除,减少导管日.
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