重症监护室护理记录单的改进与应用

目的 对重症监护室原有的护理记录单进行改进,使其更全面细致地反映重症监护室病人的病情变化和护理过程,减少护士记录时间.方法 在我院原重症监护护理记录单的基础上,增加了监护项目、用英文缩写字母或数字代替文字记录.结果 经过1年的培训、应用和完善,重症监护室的护士已经全部掌握了记录方法,缩短了记录时间.结论 新版<重症监护护理记录单>,达到了记录的便捷与高效,使及时记录得以落实,减轻了书写工作量,使护士有更多的时间和精力为患者提供直接护理服务.     

重症监护室护理记录单的改进与应用

目的 对重症监护室原有的护理记录单进行改进,使其更全面细致地反映重症监护室病人的病情变化和护理过程,减少护士记录时间.方法 在我院原重症监护护理记录单的基础上,增加了监护项目、用英文缩写字母或数字代替文字记录.结果 经过1年的培训、应用和完善,重症监护室的护士已经全部掌握了记录方法,缩短了记录时间.结论 新版〈重症监护护理记录单〉,达到了记录的便捷与高效,使及时记录得以落实,减轻了书写工作量,使护士有更多的时间和精力为患者提供直接护理服务.     

简化并前移护理记录模式的临床应用

[目的]改变原传统护理记录模式,有效缩短护理记录时间,减少书写差错,提高病人满意度。[方法]实验组随机抽取100例留置尿管病人,将简化后的管路护理记录单悬挂在病人床尾,护士在病床前实施观察和记录;对照组随机抽取100例留置尿管病人,将管路护理记录单按传统方式放于病历中,护士观察病情后将观察到的记录内容暂记到临时记录本中,回到护士站转抄至护理记录单中。分别观察记录两组护士记录时间、书写差错率以及病人满意度。[结果]实验组护士记录所需时间明显少于对照组(P<0.001);实验组无书写差错发生,对照组为6%;病人对实验组的满意率明显高于对照组(P<0.05)。[结论]简化并前移护理记录模式的实施,能有效缩短护理记录时间,减少书写差错率,提高病人对护理工作的满意度。     

简化并前移护理记录模式的临床应用

[目的]改变原传统护理记录模式,有效缩短护理记录时间,减少书写差错,提高病人满意度。[方法]实验组随机抽取100例留置尿管病人,将简化后的管路护理记录单悬挂在病人床尾,护士在病床前实施观察和记录;对照组随机抽取100例留置尿管病人,将管路护理记录单按传统方式放于病历中,护士观察病情后将观察到的记录内容暂记到临时记录本中,回到护士站转抄至护理记录单中。分别观察记录两组护士记录时间、书写差错率以及病人满意度。[结果]实验组护士记录所需时间明显少于对照组（P〈0．001）;实验组无书写差错发生,对照组为6％;病人对实验组的满意率明显高于对照组（P〈0．05）。[结论]简化并前移护理记录模式的实施,能有效缩短护理记录时间,减少书写差错率,提高病人对护理工作的满意度。     

重症监护临床信息系统的应用和效果探讨

目的:介绍重症监护临床信息系统(ICIP系统)的临床应用和取得的成效。方法:统计并比较ICIP护理记录模式和手工护理记录模式的差异。结果:ICIP护理记录的质量明显高于手工记录,且ICIP护理记录耗费的时间明显减少。结论:ICIP系统的使用明显改进了ICU护理工作,简化了流程,大大缩短了护理记录时间,使护理工作真正做到了把护士还给患者。     

专科(儿内科)护理记录电子版在优质护理中的应用和研究

目的 探讨专科护理记录电子版在儿科优质护理服务中的应用效果。方法 采用随机对照的方法,将儿内科患儿204例,按护士包干责任制随机分为责任一组 ( 实验组) 和责任二组( 对照组) ,实验组和对照组各102例。实验组由责任护士运用电子编程的专科表格式护理记录单进行电子录入,对照组采用传统护理记录单手工书写。比较两组护士书写每份护理记录的时间(首次新病例记录时间、入院第二天记录时间、常规频度的记录时间、病情变化的记录时间)、及护理人员对两种不同护理文件书写的满意率。结果 实验组的护理记录时间明显低于对照组(P＜0.01),而护理人员的满意率明显高于对照组(P＜0.05)。结论 使用专科护理记录电子版以操作简单、格式规范、时效性强、可在线保存、随时查阅等优点,减少护士书写时间,保证护士有足够的时间承担临床护理工作,对儿科优质护理服务工程效果明显;同时实现了护理文件书写信息化管理。     

病房实行责任包干制护理模式的效果观察

目的 探讨病房实行责任包干制护理模式的效果.方法 经过宣传动员、反复论证,2010年6-8月科室将病房床位分为3组,每组包干7～8张床位,由1名护理组长及3名责任护士负责组内7～8例病人的全部护理工作,包括入出院护理、基础护理、专科护理、治疗、病情观察、护理记录、心理护理、健康教育等.与实行责任包干制前(2010年1-5月)功能制护理排班模式时的护理效果进行比较.结果 实行责任包干制护理模式前(2010年1-5月),护理组长的岗位职责完成情况只有33%,责任护士平均每月加班16 h,病人说出责任护士姓名者为45%,责任护士掌握病人"十知道"满分的只有62%;实行责任包干制护理模式后(2010年6-8月),护理组长岗位完成情况达100%,责任护士无加班,护士对责任包干制排班支持率为100%,病人说出责任护士姓名者为88%,责任护士掌握病人"十知道"满分的为91%.实行责任包干制护理模式后病人满意度高于实施前(P＜0.05).结论 病房实行责任包干制护理模式后,减少了工作量,能更好地发挥护理组长的作用,提高了工作质量与效率,提高了健康教育效果及病人满意度.     

1110份ICU重症护理记录单质量考评与总结分析

目的举证倒置的新形势下,在维护好患者权利的同时,要求护士依法从事护理服务,增强证据意识,重视证据管理,进一步提高护士书写重症护理记录单的水平.方法选择从2004年1～10月入住ICU所有患者的1110份重症护理记录单,逐份质量考评,进行了总结分析,剖析了我院ICU重症护理记录单书写中存在的常见缺陷.结果认为重症护理记录单是护理文件的重要项目之一,重症护理记录单的书写和管理是履行法律责任.护士通过对病情细心地观察,认真地记录,积累了大量完整的基础资料,为危重病人的治疗、病情分析、提供有价值的信息.通过重症护理记录可以检查护士对危重病人的护理工作质量,总结经验,为医疗、护理、教学、科研,提供宝贵资料.结论对危重病人必须及时地、认真地、具有科学性地进行记录病情变化、治疗、用药、护理等项内容.加强护士法律知识学习和书写技能的培训,提高护士业务综合素质,加强重症护理记录单质量考评和重视过程质控是保证质量的关键.     

儿童早期预警评分护理记录模板的设计及应用

目的 基于儿童早期预警评分制订路径式护理记录模板,并探讨其在危重呼吸系统疾病住院患儿病情观察中的应用效果。方法 选取安徽省某三级甲等儿童专科医院试点病区2017年1月—9月呼吸系统疾病住院患儿 110 例为试验组,2016年1月—9月呼吸系统疾病住院患儿 110例为对照组, 试验组临床应用儿童早期预警评分评估病情并采用护理记录模板记录,对照组常规进行病情观察和护理记录,比较两组患儿病重时数、心电监护时数、吸氧时数、住院天数、住院费用、转入儿童重症监护室例数和护理记录缺陷等指标。 结果 试验组住院费用、转入儿童重症监护室例数低于对照组（P＜0.05）;护理记录缺陷明显减少。 访谈护士结果显示,该模板可以减少单例患儿单次护理记录书写时间10~15 min。 结论 使用儿童早期预警评分护理记录模板记录患儿病情,可以提高护理记录书写质量,减少护士书写护理记录时间,增加护士直接评估病情和进行护理干预的时间,减少呼吸系统疾病患儿非计划儿童重症监护病房入住率,降低住院费用。     

1110份ICU重症护理记录单质量考评与总结分析

目的举证倒置的新形势下，在维护好患者权利的同时，要求护士依法从事护理服务，增强证据意识，重视证据管理，进一步提高护士书写重症护理记录单的水平。方法选择从2004年1～10月入住ICU所有患者的1110份重症护理记录单，逐份质量考评，进行了总结分析，剖析了我院ICU重症护理记录单书写中存在的常见缺陷。结果认为重症护理记录单是护理文件的重要项目之一，重症护理记录单的书写和管理是履行法律责任。护士通过对病情细心地观察，认真地记录，积累了大量完整的基础资料，为危重病人的治疗、病情分析、提供有价值的信息。通过重症护理记录可以检查护士对危重病人的护理工作质量，总结经验，为医疗、护理、教学、科研，提供宝贵资料。结论对危重病人必须及时地、认真地、具有科学性地进行记录病情变化、治疗、用药、护理等项内容。加强护士法律知识学习和书写技能的培训，提高护士业务综合素质，加强重症护理记录单质量考评和重视过程质控是保证质量的关键。     

Time accuracy of a barcode system for recording resuscitation events: laboratory trials

Barcode systems for recording clinical data from resuscitation attempts offer the prospect of more complete and time-accurate data collection; in addition, collection of data in digital form and the resulting ease of computer processing promises to facilitate data analysis for quality improvement and research. We conducted trials of such a barcode system, recording events during a videotaped, simulated in-hospital resuscitation, with particular attention to time accuracy. METHODS: Nine subjects watched a videotape of a simulated cardiac resuscitation, recording events first with the barcode system and then with a conventional handwritten form. Recorded times were compared to an accurate record of events (gold standard) from the videotape. RESULTS: Mean absolute errors and standard deviations of errors from the gold standard were significantly smaller with the barcode system (P < 0.01 for both). Numbers of event omissions did not differ significantly. CONCLUSION: The barcode system is more accurate than conventional handwritten recording in capturing event times from a simulated resuscitation. The system shows promise as a means to improve time accuracy of resuscitation records.     

A data acquisition system for clinical research

We developed a system for automatic collection and synchronization of multiple physiological variables during clinical investigations. Centered around an eight-track instrumentation tape recorder, the system solves several problems encountered in gathering this type of research data: (1) slowly changing variables are digitized and compressed onto a single track by recording them in one serial message, allowing for recording many more variables than there are tape tracks available; (2) simultaneous analog recording allows retention of original data for variables that may be processed subsequently by multiple schemes; (3) data acquisition is verified with both analog chart recording and numerical video display monitors; (4) off-line computer processing time is decreased at least twofold by using tape playback speeds faster than the recording speed; (5) cost is kept low by using an inexpensive 1/4-inch (0.64-cm) tape medium and dedicated microcomputers; and (6) the system is unobtrusive, portable, and easily reconfigured for different clinical studies. It proved to be reliable in a study of more than 80 patients undergoing cardiac surgery.     

The effect of a critical care outreach service and an early warning scoring system on respiratory rate recording on the general wards

AIM: To determine whether the implementation of a Reading-Modified Early Warning Scoring (R-MEWS) system, is associated with an increased recording of respiratory rate (RR) in hospital inpatients, and whether the presence of a critical care outreach (CCO) service has a further impact on the recording of patient's vital signs. METHOD: Five annual point prevalence surveys of all adult, non-obstetric acute inpatients (n=2638) in two Hospitals (A and B) were carried out between 2001 and 2005. The R-MEWS system was implemented incrementally in both hospitals to include all study group patients, but a CCO service was only available in Hospital A. Data were collected on numbers of patients, routinely documented physiological observations and R-MEW score. RESULTS: Respiratory rate (RR) recording increased from 6.0% in the first survey to 77.9% in the last, which correlated with the incremental implementation of the R-MEWS system. Hospital A that had the CCO service showed a greater increase in RR recording than Hospital B with no CCO service. CONCLUSION: The introduction of an early warning scoring (EWS) was associated with improved respiratory rate recording, which may have been further enhanced by the presence of a CCO service.     

Consistency of the Automatic Algorithm in Detecting Complex Fractionated Electrograms using an Electroanatomical Navigation System

Background: The different settings of the automatic algorithm in the Carto system (Carto XP, Biosense Webster, Diamond Bar, CA, USA) used for detecting complex fractionated electrograms (CFEs) during atrial fibrillation (AF) may influence the identification of the fragmented electrograms. Objectives: We aimed to evaluate the impact of the different parameters on the detection of CFEs and the efficacy of the substrate modification after pulmonary vein isolation (PVI). Methods: A total of 1,159 electrograms were analyzed from 11 consecutive patients (age = 56 ± 12 years). The effect of the different algorithm factors, such as the high-voltage thresholds (0.12, 0.25, 0.5, 20 mV), detection algorithms (average complex interval [ACI] vs interval confidence level), and recording duration (2.5 seconds vs 5 seconds), on the disparities of the CFEs was investigated. Results: The proportion of the different grades of CFEs depended on the detection algorithm and recording duration. The high-voltage threshold would not affect the consistency of the CFEs irrespective of the different settings of the detection algorithm or recording duration. High-grade CFEs were most consistent with an ACI algorithm and recording duration of 5 seconds (Cronbach's alpha = 0.952). Ablation consisting of a PVI and high-grade CFE sites converted AF directly to sinus rhythm in eight of 11 patients or into atrial tachycardia in one of 11. Conclusions: The distribution and consistency of the CFE detection depended on the detection algorithm and recording duration, but not on the high-voltage threshold. Under the ACI algorithm and a recording duration of 5 seconds, high-grade CFE sites remained highest consistency. (PACE 2012; 35:980-989).     

The development of the Stroke Physiotherapy Intervention Recording Tool (SPIRIT)

Purpose: To develop a recording system that describes physiotherapy interventions for the rehabilitation of postural control post-stroke.

Methods: Design: A draft recording tool was developed using the method described by Edwards et al,¹² involving literature searches and collaboration with senior clinicians. It was piloted with stroke physiotherapists using a cross-sectional survey design to assess validity, utility and completeness. Participants used the recording tool to record five treatment sessions. Feedback regarding the utility and completeness of the system was obtained via short semi-structured interviews. Setting: 11 NHS Trusts. Participants: 35 stroke physiotherapists working in acute and rehabilitation settings recorded the treatment of 120 patients in 590 treatment sessions.

Results: A double-sided A4 form with a checklist of 79 physiotherapy interventions in 9 categories was produced: the Stroke Physiotherapy Intervention Recording Tool (SPIRIT). The participants found it quick and easy to use and reflective of clinical practice. There were a few missing interventions and some confusion regarding definition of terms. Revisions were to include the omitted interventions and to produce a user's booklet defining the categories and interventions.

Conclusions: SPIRIT provides a system for recording physiotherapy treatment for stroke patients which reflects current clinical practice in acute and rehabilitation settings.     

Computerized recording of neuromuscular monitoring and the risk of residual paralysis at the time of extubation

OBJECTIVE : We tested whether a newly installed neuromuscular monitoring device (NMT) with a computerized anesthesia recording system, incorporated in all anesthesia stations, could enhance the commitment to objective neuromuscular monitoring in a teaching hospital anesthesia department. METHODS : After 6 months of familiarization with the new package, we retrospectively assessed 500 consecutive anesthesia records from our database. The main criteria were the use of the NMT device, the administration of pharmacological reversal, the relaxants regimen, and duration of anesthesia and surgery. RESULTS : A total of 486 anesthesia records were analyzed. The rate of NMT utilization was 72%, while the rate of reversal was of 46%. 4% of patients were both not monitored and not reversed. The NMT was most used on patients having longer surgery. Time delay from reversal injection to extubation was significantly shorter in patients who were not monitored; 9+/-7 min vs. 16+/-10 min, P<0.001. CONCLUSION : Despite the presence of quantitative objective neuromuscular monitoring in all operating rooms, and the automatic data recording system, the rate of monitoring neuromuscular blockade was not high enough to rule out the potential risk of residual paralysis at the time of extubation.     

The development of the Stroke Physiotherapy Intervention Recording Tool (SPIRIT)

Purpose:?To develop a recording system that describes physiotherapy interventions for the rehabilitation of postural control post-stroke.

Methods:?Design: A draft recording tool was developed using the method described by Edwards et al,¹² involving literature searches and collaboration with senior clinicians. It was piloted with stroke physiotherapists using a cross-sectional survey design to assess validity, utility and completeness. Participants used the recording tool to record five treatment sessions. Feedback regarding the utility and completeness of the system was obtained via short semi-structured interviews. Setting: 11 NHS Trusts. Participants: 35 stroke physiotherapists working in acute and rehabilitation settings recorded the treatment of 120 patients in 590 treatment sessions.

Results:?A double-sided A4 form with a checklist of 79 physiotherapy interventions in 9 categories was produced: the Stroke Physiotherapy Intervention Recording Tool (SPIRIT). The participants found it quick and easy to use and reflective of clinical practice. There were a few missing interventions and some confusion regarding definition of terms. Revisions were to include the omitted interventions and to produce a user's booklet defining the categories and interventions.

Conclusions:?SPIRIT provides a system for recording physiotherapy treatment for stroke patients which reflects current clinical practice in acute and rehabilitation settings.     

Bronchial temperature as a key to the interior pulmonary capillary bed of anaesthetized dogs

The terminal airways are separated from the surrounding pulmonary capillaries by a tissue layer of a few micrometers in thickness only. Therefore, it should be possible to gain information about in vivo transcapillary heat transport of the interior pulmonary vascular bed by recording the terminal bronchial temperature. For this purpose, we studied temperature-time curves in the pulmonary artery, bronchial system and the aorta of six anaesthetized dogs permanently instrumented for measuring pulmonary blood flow. Thermistors recorded temperature changes at the three locations after injection of 5 ml cold solution into the right atrium. From the observed temperature-time curves mean transit times between the three recording sites were calculated for various pulmonary blood flows (ŒΔTtdt/ŒΔTdt) (range 1.1–3.5 l/min). We found that the temperature-time curves of the bronchial system resemble typical “dilution” curves and are interspaced between those in the pulmonary artery and those in the aorta. Regardless of pulmonary blood flow, mean transit times from the pulmonary artery to the distal bronchial system and from there to the aorta were about equal. We conclude that transcapillary heat transfer generates bronchial temperature-time curves which permit an estimation of the relation of precapillary to postcapillary mean transit times in the interior of the lung. Received: 21 August 1996 Accepted: 16 June 1997     

人体上肢表面肌电反馈康复训练系统的研制

目的：研究临床康复训练中急需解决的肌肉疲劳的保护问题。方法：开发了一种采用功能电刺激方式和表面肌电反馈控制的康复训练系统。该系统由功能电刺激器、被动训练发生器、表面肌电信号放大器及管理控制软件4部分组成。管理控制软件控制表面肌电信号放大器、功能电刺激器和被动训练发生器3部分的协调运作。结果：该系统可以实时分析康复训练过程中采集到的表面肌电信号，并以此判定肌肉是否疲劳，亦可设定功能电刺激系统的刺激参数，通过控制电路控制训练发生器运动参数等功能。结论：该系统可以有效地防止主动训练过程中因肌肉过度疲劳而造成的损伤。     

Multi-channel fiber photometry for population neuronal activity recording

Fiber photometry has become increasingly popular among neuroscientists as a convenient tool for the recording of genetically defined neuronal population in behaving animals. Here, we report the development of the multi-channel fiber photometry system to simultaneously monitor neural activities in several brain areas of an animal or in different animals. In this system, a galvano-mirror modulates and cyclically couples the excitation light to individual multimode optical fiber bundles. A single photodetector collects excited light and the configuration of fiber bundle assembly and the scanner determines the total channel number. We demonstrated that the system exhibited negligible crosstalk between channels and optical signals could be sampled simultaneously with a sample rate of at least 100 Hz for each channel, which is sufficient for recording calcium signals. Using this system, we successfully recorded GCaMP6 fluorescent signals from the bilateral barrel cortices of a head-restrained mouse in a dual-channel mode, and the orbitofrontal cortices of multiple freely moving mice in a triple-channel mode. The multi-channel fiber photometry system would be a valuable tool for simultaneous recordings of population activities in different brain areas of a given animal and different interacting individuals.OCIS codes: (170.0170) Medical optics and biotechnology, (180.2520) Fluorescence microscopy, (170.2150) Endoscopic imaging, (170.2655) Functional monitoring and imaging