46例前置胎盘孕妇临床观察与护理

目的 加强对前置胎盘孕妇的产前产后全面临床观察与护理，早期发现和预防妊娠晚期出血。方法 回顾46例前置胎盘孕妇的临床资料。结果 46例前置胎盘孕妇经产前健康教育、生活指导、严密临床观察护理及输液、输血、抗感染等治疗。产后做好围产儿护理，预防产后出血，均治愈出院。结论 加强对妇女的卫生知识教育，宣传避孕常识。避免多次刮宫、剖宫产或宫腔感染，减少子宫内膜损伤或子宫内膜炎发生可预防前置胎盘的发生。产科工作人员要加强对前置胎盘的认识，做到旱诊断、早治疗。凡有前置胎盘可疑时，且不可轻易做阴道检查或肛门检查，以免造成大量出血。     

慢性肾小球肾炎综合护理临床护理体会

目的：探讨分析综合护理干预在慢性肾小球肾炎治疗护理应用中的临床效果。方法：以随机数字表法将150例慢性肾小球肾炎患者分为对照组和观察组,对照组患者75例,观察组患者75例。对照组患者给予常规护理,观察组在对照组的基础上给予综合护理干预,对比分析两组患者治疗前后的护理效果。结果：治疗护理后,观察组患者焦虑缓解状况和抑郁缓解状况显著高于对照组(P<0.05);两组患者血肌酐、尿素氮均有所下降,血浆白蛋白均有所提高,观察组患者血肌酐、尿素氮水平下降幅度和血浆白蛋白升高水平更为显著(P<0.05);观察组患者生活满意度和对照组相比较更高,情感指数和健康指数更高(P<0.05)。结论：综合护理可以有效提高慢性肾小球肾炎患者的治疗效果,提高患者满意度。     

奥拉西坦改善阿尔茨海默病患者神经功能与记忆功能的综合护理效果

目的:探讨综合护理方法在阿尔茨海默病患者奥拉西坦治疗中的应用效果.方法:选取2013年5月至2017年1月哈尔滨医科大学附属第二医院收治的86例阿尔茨海默病患者作为研究对象,按入院时间将其分为对照组(2013年5月至2015年5月)和干预组(2015年6月至2017年1月),每组43例.所有患者予以阿尔茨海默病常规基础联合奥拉西坦等药物对症治疗,对照组予以常规临床护理,干预组患者予以综合护理模式干预,两组均干预两周.干预结束后比较两组神经功能、记忆功能、生活质量和抑郁情况,以及患者/患者家属对护理的满意度.结果:干预后两组美国国立卫生研究院卒中神经功能缺损评分(National Institute of Health stroke scale,NIHSS)较干预前明显降低,而韦氏记忆测试修订版(Wechsler Memory Scale-Revised,WMS-R)评分均较干预前明显升高,差异有统计学意义(P<0.05),但两组干预后比较,差异无统计学意义(P>0.05);两组干预后其日常生活自理能力表(Activity of Daily Living Scale,ADL)和汉密尔顿抑郁量表(Hamilton Anxiety Scale,HAMA)评分均较干预前降低,且干预组降低程度明显大于对照组,差异有统计学意义(P<0.05);干预组护理总满意度与对照组比较差异有统计学意义(97.67％vs 83.72％,P<0.05).结论:综合性护理可明显提高予以奥拉西坦治疗的阿尔茨海默病患者的生活质量,并降低其抑郁程度,同时更易于被患者及家属所接受,可作为临床上阿尔茨海默病患者的优选护理模式.     

Enhancing Nursing Students' Experience in the Assessment and Care of Vascular Access Devices

BackgroundBachelor of Science in Nursing students get minimal exposure or experience in the assessment and care of vascular access devices (VADs) let alone the placement of such devices. Students in our university nursing program receive no structured experience. Students learn how to assess and care for VADs in the clinical setting while working with clinical faculty and staff nurse mentors.PurposeThe purpose of this pilot program was to increase the awareness and understanding of VADs for third-year nursing students to enhance their comfort level in assessing and caring for these devices.MethodsThirty-two third-year nursing students, in groups of 8, participated in this pilot program in addition to their usual academic and clinical assignments. The 4 structured components of this program included a didactic session to share basic VAD information, simulation laboratory time to practice peripheral intravenous line insertion, a 4-hour one-to-one shadowing experience with a vascular access service team registered nurse providing patient care, and a wrap-up session by the vascular access service team educational nurse coordinator to provide debriefing and additional information.ConclusionsStudents who participated in this pilot program expressed an increased level of comfort regarding VADs. They came away with knowledge that other nursing students in the program do not receive during their academic and clinical time.     

临床护理路径在门诊糖尿病患者健康教育的应用

目的为探讨临床护理路径在门诊糖尿病患者健康教育的可行性,提高健康教育的质量。方法将300例糖尿病患者随机分为实验组(150例)和对照组(150例),实验组按照临床护理路径进行健康教育,对照组接受传统的健康教育。结果实施临床护理路径之后,克服了护理工作的盲目性,使患者掌握糖尿病的有关知识和自我护理监测方法,降低糖尿病并发症的发生,实验组与对照组比较,有非常显著性差异(P<0.001)。结论临床护理路径在糖尿病中是最佳的医疗护理服务模式,同时也体现了质量管理的最终目标是病人满意这一宗旨,因此值得临床推广应用。     

肛裂患者术后采用系统化护理措施治疗便秘的临床疗效观察

目的：观察肛裂患者术后采用系统化护理措施治疗便秘的临床疗效。方法：选取2013年8月至2015年8月于我院诊治的肛裂术后患者220例,随机分为系统化护理组与常规护理组,每组110例。常规护理组患者采用常规护理措施,系统化护理组在常规护理组基础上采用系统化护理措施。比较两组患者术后便秘情况、排便分级情况、术后并发症及护理满意度。结果：与常规护理组相比,系统化护理组患者术后3天内有大便、用力排便、大便密结干硬、排便不尽感发生率较低(P<0.01)。与常规护理组相比,系统化护理组患者术后3天、5天排便分级0级率较高、2级率较低(P<0.05)。与常规护理组相比,系统化护理组患者术后切口裂开、切口感染发生率较低,住院天数较短,护理满意度较高(P<0.05)。结论：肛裂患者术后采用系统化护理措施可改善便秘情况,降低术后并发症及提高护理满意度。     

Effectiveness of a Web-Based Simulation in Improving Nurses’ Workplace Practice With Deteriorating Ward Patients: A Pre- and Postintervention Study

Background

Nurses play an important role in detecting patients with clinical deterioration. However, the problem of nurses failing to trigger deteriorating ward patients still persists despite the implementation of a patient safety initiative, the Rapid Response System. A Web-based simulation was developed to enhance nurses’ role in recognizing and responding to deteriorating patients. While studies have evaluated the effectiveness of the Web-based simulation on nurses’ clinical performance in a simulated environment, no study has examined its impact on nurses’ actual practice in the clinical setting.

Objective

The objective of this study was to evaluate the impact of Web-based simulation on nurses'' recognition of and response to deteriorating patients in clinical settings. The outcomes were measured across all levels of Kirkpatrick’s 4-level evaluation model with clinical outcome on triggering rates of deteriorating patients as the primary outcome measure.

Methods

A before-and-after study was conducted on two general wards at an acute care tertiary hospital over a 14-month period. All nurses from the two study wards who undertook the Web-based simulation as part of their continuing nursing education were invited to complete questionnaires at various time points to measure their motivational reaction, knowledge, and perceived transfer of learning. Clinical records on cases triggered by ward nurses from the two study wards were evaluated for frequency and types of triggers over a period of 6 months pre- and 6 months postintervention.

Results

The number of deteriorating patients triggered by ward nurses in a medical general ward increased significantly (P<.001) from pre- (84/937, 8.96%) to postintervention (91/624, 14.58%). The nurses reported positively on the transfer of learning (mean 3.89, SD 0.49) from the Web-based simulation to clinical practice. A significant increase (P<.001) on knowledge posttest score from pretest score was also reported. The nurses also perceived positively their motivation (mean 3.78, SD 0.56) to engage in the Web-based simulation.

Conclusions

This study provides evidence on the effectiveness of Web-based simulation in improving nursing practice when recognizing and responding to deteriorating patients. This educational tool could be implemented by nurse educators worldwide to address the educational needs of a large group of hospital nurses responsible for patients in clinical deterioration.     

临床路径教学模式在呼吸内科护理带教中的应用

目的：探讨临床路径教学模式运用于呼吸内科护理实习带教的效果。方法：将在我院参加呼吸内科实习的护生按入科时间分为对照组54名,干预组56名。对照组实施传统带教模式;干预组实施临床路径带教模式,即参照临床路径模式,让护生参与制定教学路径,明确教学内容及目标。比较两组护生出科时理论考核和操作考核成绩;带教老师与学生双方对实习整体满意度以及患者对护理服务的满意度评价。结果：观察组护生理论和操作考核成绩分别为(94.41±3.00)、(94.21±2.10)分,分别高于对照组护生的(91.09±3.57)、(91.91±3.52)分,差异均有统计学意义(u=741.0,P<0.0001;t=4.19,P<0.0001)。带教老师、护生对临床路径教学模式的满意度及患者对实习护生护理服务满意度分别为94.6%、98.2%、96.4%,分别高于对照组的79.6%、79.6%、85.2%,差异均有统计学意义(χ2=5.579,P=0.0182;χ2=9.77,P=0.0018;χ2=4.205, P=0.04)。结论：临床路径教学模式教学目标明确,可提高教学效率和临床护理教学质量;同时也提高了病人对护理服务的满意度。     

临床护理路径在介人治疗股骨头无菌性坏死的应用与探讨

目的建立完善的介入治疗股骨头无菌性坏死的临床护理路径，使患者手术前后的医疗护理服务规范化。方法按入院先后顺序随机将60例患者分为对照组和实验组，各30例。对照组采用按常规医嘱进行护理，实验组按临床护理路径方法制定围手术期间护理路线图进行护理，观察2组患者掌握股骨头无菌性坏死相关知识和相关技能、平均住院时间、平均住院费用、术后并发症和患者满意度有无差异。结果2组患者所获得的结果差异具有统计学意义（P〈0．01）。结论临床护理路径在介入治疗股骨头无菌性坏死的应用可有效提高护士的工作质量和患者的遵医行为，从而提高了医院的社会效益和经济效益。     

中医临床护理路径在乙肝后肝硬化患者中的应用效果分析

目的 探究中医临床护理路径在乙肝后肝硬化患者中的应用效果。方法 选取我院2017年9月~2018年9月收治的乙肝后肝硬化患者200例,随机分为实验组和对照组,每组100例。实验组给予中医临床护理路径护理,对照组给予常规护理,对比两组患者实施护理干预后其生活质量评分、不良反应发生率和患者护理满意度。结果 实验组患者躯体功能、心理功能和社会功能的质量评分均高于对照组,差异具有统计学意义（P＜0.05）。实验组并发症发生率为5.00%,低于对照组的16.00%,差异具有统计学意义（P＜0.05）。实验组患者的护理满意度为98.00%,高于对照组的88.00%,差异具有统计学意义（P＜0.05）。结论 乙肝后肝硬化患者给予中医临床护理路径,能够有效改善患者的临床症状,提高其生活质量,减少不良反应的发生率。     

Development of Standards and Criteria for the Selection, Training, and Evaluation of Athletic Training Approved Clinical Instructors

OBJECTIVE: To develop standards and associated criteria for the selection, training, and evaluation of athletic training approved clinical instructors (ACIs). DESIGN AND SETTING: A previously developed set of 7 physical therapy clinical instructor standards/criteria and 2 additional standards/criteria developed through a review of the literature were systematically adapted, judged, and revised through a Delphi technique. SUBJECTS: Athletic training education experts currently employed as program directors for entry-level Commission on Accreditation of Allied Health Education Programs-accredited athletic training educational programs and who had the following: a doctoral degree, at least 5 years of supervising athletic training students, and familiarity/experience with clinical instruction in various athletic training clinical education settings. MEASUREMENTS: We used panelists' critiques and ratings to make sequential revisions in a series of 3 Delphi rounds. Standards were rated as to whether they were clear, necessary, and appropriate. We rated criteria for the associated standard as to whether they were useful, helpful, clear, specific, and consistent. RESULTS: We developed a final set of 7 standards and 50 associated criteria to measure these standards. The accepted standards include the following: legal and ethical behavior, communication skills, interpersonal relationships, instructional skills, supervisory and administrative skills, evaluation of performance, and clinical skills and knowledge. CONCLUSIONS: The 7 standards and associated criteria developed in this research project could be used not only for selecting, training, and evaluating an ACI but also for developing an understanding of the requirements of clinical education in general. Further research should include validating these standards/criteria among athletic training ACIs representing different types of clinical settings.     

临床应用解剖学带教体会

为了加强基础医学与临床的对接,培养研究生的动手能力,参加了北京协和医学院研究生院临床应用解剖学课程的带教课程。经过几年的教学实践,对所获得的经验及存在的问题进行总结,以期为未来的教学提供借鉴。     

Designing and Evaluating an Interactive Multimedia Web-Based Simulation for Developing Nurses’ Competencies in Acute Nursing Care: Randomized Controlled Trial

BackgroundWeb-based learning is becoming an increasingly important instructional tool in nursing education. Multimedia advancements offer the potential for creating authentic nursing activities for developing nursing competency in clinical practice.ObjectiveThis study aims to describe the design, development, and evaluation of an interactive multimedia Web-based simulation for developing nurses’ competencies in acute nursing care.MethodsAuthentic nursing activities were developed in a Web-based simulation using a variety of instructional strategies including animation video, multimedia instructional material, virtual patients, and online quizzes. A randomized controlled study was conducted on 67 registered nurses who were recruited from the general ward units of an acute care tertiary hospital. Following a baseline evaluation of all participants’ clinical performance in a simulated clinical setting, the experimental group received 3 hours of Web-based simulation and completed a survey to evaluate their perceptions of the program. All participants were re-tested for their clinical performances using a validated tool.ResultsThe clinical performance posttest scores of the experimental group improved significantly (P<.001) from the pretest scores after the Web-based simulation. In addition, compared to the control group, the experimental group had significantly higher clinical performance posttest scores (P<.001) after controlling the pretest scores. The participants from the experimental group were satisfied with their learning experience and gave positive ratings for the quality of the Web-based simulation. Themes emerging from the comments about the most valuable aspects of the Web-based simulation include relevance to practice, instructional strategies, and fostering problem solving.ConclusionsEngaging in authentic nursing activities using interactive multimedia Web-based simulation can enhance nurses’ competencies in acute care. Web-based simulations provide a promising educational tool in institutions where large groups of nurses need to be trained in acute nursing care and accessibility to repetitive training is essential for achieving long-term retention of clinical competency.     

Clinical Equivalence: A Step,A Misstep,or Just a Misnomer?

Most current approaches to assess clinical significance and clinical equivalence rely principally on concepts and methods drawn from population statistics, yet these strategies fall far short of the qualitative nature of the judgments rendered by clinicians. Just as the construct of clinical diagnosis in research settings bene-fitted by drawing upon the so-called LEAD standard (longitudinal, expert, all data) to achieve research diagnoses with the greatest clinical credibility, the concepts of "clinically significant change" or "clinically equivalent to normal" need similar standards. As an alternative, for future purposes of assessing clinical significance, I recommend the application of a "SMARTER" standard, as follows: (a) whenever possible, the method should use standardized measures, (b) it should address all relevant outcomes across settings, raters, and domains; and (c) it should make use of trained expert clinicians, trained to achieve reliability.     

Stressing the (Other) Three Rs in the Search for Empirically Supported Treatments: Review Procedures, Research Quality, Relevance to Practice and the Public Interest

The Society of Clinical Psychology's task forces on psychological intervention developed criteria for evaluating clinical trials, applied those criteria, and generated lists of empirically supported treatments. Building on this strong base, the task force successor, the Committee on Science and Practice, now pursues a three-part agenda: (a) evolution of review and classification procedures with an emphasis on reliability across reviewers, (b) an active role as gadfly in promoting improved research, and (c) a dissemination program (with an evolving web site) to make our process, findings, and data base accessible to practitioners, researchers, policy makers, and the public. We seek to link practitioners and researchers in the shared goal of improving mental health care by encouraging evidence-based practice and training.     

Manual-Based Treatment: An Essential Ingredient of Clinical Practice in the 21st Century

Wilson (this issue) raises several thought-provoking issues pertaining to the use of manual-based treatments (MBTs) in clinical practice. Based on my experiences as a researcher of manual-based treatments for social phobia and as a clinical psychologist in independent practice, I share my perspective on several of Wilson's points. Comorbid conditions do not appear to hinder the outcomes of MBTs for social phobia, and participants in controlled clinical trials do not appear very different from persons who refuse or are excluded from participation. Manuals can be written in a manner that retains a great deal of flexibility for the clinician, and these manuals may be productively employed in clinical settings. Proper implementation of MBTs requires experience with the disorder of interest and a strong background in theories of psychopathology and therapy technique.     

Clinical prediction rules in practice: review of clinical guidelines and survey of GPs

Background

The publication of clinical prediction rules (CPRs) studies has risen significantly. It is unclear if this reflects increasing usage of these tools in clinical practice or how this may vary across clinical areas.

Aim

To review clinical guidelines in selected areas and survey GPs in order to explore CPR usefulness in the opinion of experts and use at the point of care.

Design and setting

A review of clinical guidelines and survey of UK GPs.

Method

Clinical guidelines in eight clinical domains with published CPRs were reviewed for recommendations to use CPRs including primary prevention of cardiovascular disease, transient ischaemic attack (TIA) and stroke, diabetes mellitus, fracture risk assessment in osteoporosis, lower limb fractures, breast cancer, depression, and acute infections in childhood. An online survey of 401 UK GPs was also conducted.

Results

Guideline review: Of 7637 records screened by title and/or abstract, 243 clinical guidelines met inclusion criteria. CPRs were most commonly recommended in guidelines regarding primary prevention of cardiovascular disease (67%) and depression (67%). There was little consensus across various clinical guidelines as to which CPR to use preferentially. Survey: Of 401 responders to the GP survey, most were aware of and applied named CPRs in the clinical areas of cardiovascular disease and depression. The commonest reasons for using CPRs were to guide management and conform to local policy requirements.

Conclusion

GPs use CPRs to guide management but also to comply with local policy requirements. Future research could focus on which clinical areas clinicians would most benefit from CPRs and promoting the use of robust, externally validated CPRs.     

Genetic drift. The real tiger mother: from the clinical geneticist's perspective

The Battle Hymn of the Tiger Mother by Amy Chua raises questions about motherhood and what is admirable. Chua promotes strict, Old World, uncompromising values stressing academic performance above all, insisting on drilling and practice, and instilling respect for authority. As clinical geneticists, we meet an entirely different type of mother than Chua, the clinical genetics mother who fights illnesses, schools, hospital policies, and insurance companies. She battles not against her child but for her child. With brilliance and resilience, she creates a child-centered world. The stories of four clinical genetics mothers rally us to reject extreme parenting and appreciate the simple joys of childhood.     

Antiviral Potency of HAART Regimens and Clinical Success Are Not Strictly Coupled in Real Life Conditions: Evidence from the MASTER-1 Study

Abstract

Purpose: To compare in a real clinical setting the largely unknown midterm clinical effectiveness of two protease inhibitor (PI)-based highly active antiretroviral therapy (HAART) regimens with different potency and tolerability profiles in naïve patients. Method: This study was a multicenter, open-label, randomized trial in naïve patients with less than 400 CD4+ cell count/μL, regardless of viral load. Treatment arms were hard gel capsule saquinavir (HGC-SQV)-based HAART (Arm A), with an expected more favorable tolerability profile, and indinavir (IDV)-based HAART (Arm B), with more potent virologic activity. While viro-immunological surrogate markers and World Health Organization (WHO) grade III toxicity (secondary endpoints) were regularly monitored, primary endpoints of the study were clinical and defined as any AIDS-defining event, AIDS-related death, WHO grade IV toxicity, drop outs, and protocol violations. Results: 262 consecutive patients were enrolled in the study from March 1, 1997 to December 31, 1997, in 24 different Italian clinical centers (132, Arm A; 130, Arm B). After 24 months of follow-up, patients who were enrolled in Arm B showed a significantly higher rate of virological success (75% had viremia below 500 copies/mL, CI = 12.9%, in the on-treatment analysis) and immunological gain (mean CD4+ cell count increase of 274 CD4+ cells/μL, SD = 234) when compared to patients enrolled in arm A (57%, CI = 15.5% and 223 CD4+ cells/μL, SD = 192; p = .0353 and .026, respectively). Despite the significant difference observed in surrogate markers, the number of total primary endpoints did not differ in the two groups (55 out of 132 in Arm A vs. 58 out of 130 person-years in Arm B; p = .86). Conclusion: Our results suggest that, after 24 months of follow-up in a real clinical setting, a PI-based HAART induces significant clinical benefits in naïve patients even in the absence of a complete suppression of viral replication. However, the long-term clinical impact of the possible accumulation of viral mutations in the presence of low-grade viral replication remains to be elucidated.