某內外科加護病房護理人員執行護理評估正確率之改善方案

Project to Enhance Accuracy of Nursing Assessments Performed by Medical and Surgical ICU Nursing Staffs

10.6224/JN.58.3S.47

劉淑倩(Shu-Chien Liu)；王宜卉(I-Hui Wang)；唐敏華(Min-Hua Tang)；余慧蘭(Hui-Lan Yu)；李承泠(Cheng-Ling Lee)；劉雅菁(Ya-Jing Liu)

護理評估 ； 加護護理人員 ； 評估指引 ； nursing assessment ； ICU nursing staff ； nursing assessment guidelines

護理雜誌

58卷3期附冊（2011 / 06 / 01）

47 - 55

繁體中文

背景　臨床發現部分人員未正確評估身體各系統，且人員無法立即判讀檢驗值所代表之意義，影響照護品質及病人安全。本組於2009年10月16日至10月29日，運用「加護護理人員執行護理評估正確性查核表」針對內外科成人加護病房進行現況資料分析，發現加護護理人員執行護理評估正確率偏低，僅63.4%，主要原因有：1.護理評估認知不足、2.未落實護理評估評核機制、3.護理評估依經驗傳承、4.缺乏護理評估指引。 目的　本專案旨在提升加護護理人員護理評估執行正確率，及提升加護護理人員護理評估認知。 解決方案　1.製作加護護理人員護理評估指引；2.製作加護護理人員護理評估學習光碟；3.舉辦加護護理人員護理評估臨床情境模擬演練為專案的解決方案。 結果　加護護理人員執行護理評估正確率提升至85.8%；加護護理人員對護理評估認知平均得分由68.7分提升至83.1分。 結論　本專案確實可以改善加護護理人員執行護理評估正確率，有鑑於此，希望此方案可提供相關醫療單位之參考。

Background: Some nurses do not have the skills necessary to evaluate general ICU patient condition and the meaning of laboratory data adequately. This can influence nursing care quality and patient safety. Between October 16th and 29th, 2009, this project employed a checklist to evaluate nursing assessment accuracy in medical and surgical ICUs. The unexpectedly low accuracy rate of two-thirds (63.4 percent) was caused by factors including poor nursing assessment cognizance, lack of experience performing nursing assessments, nursing assessment skills taught only to experienced nursing staff, and a lack of nursing assessment guidelines. Purpose: This project was designed to improve nursing assessment cognizance and accuracy among nursing staff Resolution: The authors: 1. Established formal nursing assessment guidelines; 2. made a CD-ROM to introduce nursing assessment basics; and 3. employed lectures and simulation exercises to teach nursing assessment skills. Results: Nursing assessment accuracy improved significantly to 85.8 percent and actual nursing assessment cognizance scores ranged between 68.7 and 83.1. Conclusions: This project effectively improved nursing assessment accuracy and may be considered and referenced by relevant medical organizations.