主管:国家卫生健康委员会
主办:国家卫生健康委医院管理研究所
中国科技核心期刊(中国科技论文统计源期刊)
中国科学引文数据库(CSCD)核心库期刊
《中文核心期刊要目总览》核心期刊

中国护理管理 ›› 2024, Vol. 24 ›› Issue (7): 961-966.doi: 10.3969/j.issn.1672-1756.2024.07.001

• 特别策划·心力衰竭容量管理 • 上一篇    下一篇

心力衰竭患者出入量记录表的设计与应用

温雅 倪云霞 贺莉 王倩 田晓萌 游桂英   

  1. 四川大学华西医院心脏内科/四川大学华西护理学院,610041 成都市
  • 出版日期:2024-07-15 发布日期:2024-07-15
  • 通讯作者: 游桂英,本科,主任护师,护士长, E-mail:guiying_you@163.com
  • 作者简介:温雅,硕士,副主任护师,专科副护士长

Design and application of volume record sheet for patients with heart failure

WEN Ya, NI Yunxia, HE Li, WANG Qian, TIAN Xiaomeng, YOU Guiying   

  1. Department of Cardiology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, 610041, China
  • Online:2024-07-15 Published:2024-07-15
  • Contact: E-mail:guiying_you@163.com

摘要: 目的:设计心力衰竭患者出入量记录表并评价其临床应用效果,为提高心力衰竭患者的容量管理质量提供依据。方法:采用文献研究、小组讨论、头脑风暴等方法设计心力衰竭患者出入量记录表。便利选取四川省某三级甲等医院的住院心力衰竭患者为研究对象,比较应用出入量记录表前后患者出入量记录完整率、记录规范率、口服补钾及时率、居家记录依从率和出院3个月内的再入院率。结果:应用出入量记录表后,心力衰竭患者出入量记录完整率、记录规范率、口服补钾及时率及居家出入量记录依从率分别提升32.7%、10.1%、22.1%、19.9%,差异有统计学意义(P<0.05);应用出入量记录表前、后心力衰竭患者的再入院率比较,差异无统计学意义(P>0.05)。结论:心力衰竭患者出入量记录表的应用有助于规范出入量记录流程,提高记录完整率、规范率和居家记录依从率,为容量管理决策提供了科学参考。

关键词: 心力衰竭;容量管理;表格;记录管理

Abstract: Objective: To design a volume record sheet for patients with heart failure and identify its clinical application effects, and to provide a reference for volume management quality improvement. Methods: The volume record sheet was designed based on literature review, group discussions, and brainstorming. Participants with heart failure were conveniently selected from a tertiary grade A hospital in Sichuan province. The rates of volume records, the standardization of records, the timely treatments of oral potassium, the compliance of recording at home, and the readmission rates in 3 months after discharge were compared before and after the application of the recording sheet. Results: After the application of the volume record sheet, the rates of volume records, the standardization of records, the timely treatments of oral potassium, and the compliance of recording at home in patients with heart failure were increased significantly by 32.7%, 10.1%, 22.1%, and 19.9%, respectively (P<0.05). There was no statistically significant difference in 3-month readmission (P>0.05). Conclusion: The application of volume record sheet in patients with heart failure is helpful to standardize the volume record process, improve the record completeness and standardization, to increase record compliance at home, and further provides a scientific reference for better volume management decision.

Key words: heart failure; volume management; forms; records control

中图分类号:  R47;R197