岳莹 牛丽君 吕慧颐 岳莹 牛丽君(030001，山西医科大学第二医院)；吕慧颐(030001，山西医科大学第一医院) 山西护理杂志 1999 0 13 3


    关键词：整体护理；护理措施；护理病历Issues；Existed；in；Nursing；Care；Measures；of 期刊 sxhlzz 0 专题笔谈：系统化整体护理 fur -->


    

摘要 随机抽取我科1997年3月—11月100份整体护理病历，对其中814个护理问题对应的4655条护理措施进行分析，结果陈述不清楚、欠条理的265条(5.7%)，措施可行性差147条(3.2%)，护理措施与护理问题不符107条(2.3%)，措施缺乏科学依据88条(1.9%)， 护理措施与医疗措施混淆201条(4.3%)。提出：正确掌握护理措施意义及范畴，遵循护理措施与护理问题一致的原则，从实际出发，制定切实可行的有效的护理措施。

    中国图书资料分类号 R197.323

100 Cases Nursing Medical Record and Its Countermeasure

Yue Ying,Niu Lijun，Lü Huiyi(Second Hospital of Shanxi Medical University,Shanxi 030001 China)

Abstract 100 cases holistic nursing care medical records were taken out randomly dated from Mar.to Nov.of 1997.And 4655 pieces of nursing care measures of 814 issues were analysed.Results showed that 265 pieces(5.7%) statements were unclear and poor-organized;147 pieces(3.2%)of measures were with poor feasibility;107 pieces(2.3%) of measures did not tally with issues;88 pieces (1.9%)of measures lacked of scientific basis;and 201 pieces(4.3%)mixed up nursing care measures with medical measures.Proposed that one grasp the meaning and category of nursing care correctly,follow the principle of nursing care measures being consistent with nursing issues,and proceed from actual conditions,make out feasible and effective nursing care measures.

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