随着医保改革和精细化管理的不断推进,加大对医疗服务行为的管理、寻求成本管控是必然趋势,DRGs支付改革在影响医疗管理的同时,对护理管理也提出了更高的要求.文章综述了 DRGs 支付改革对护理管理观念、护理经济价值评价、护士执业环境方面的影响.护理管理者应主动探索 DRGs 与护理工作量的关系及其在人力资源配置中的指导作用,包括主动调控,提高护理人力资源效能;多维度探索,合理评价护理经济价值;优化模式,适应医疗体制改革;仔细核查,配合抓好病案首页质量,从而更好地适应DRGs支付改革.

随着我国医疗体制改革的逐步推进,三甲医院发展过程中迎来了信息社会带来的发展机遇.医院信息数据包含大量的医疗信息,包括患者和医院基础设施数据.为了更好地促进医疗行业的健康发展,医院管理部门需要充分重视信息统计的重要性,同时,医院管理水平的高低也与数据分析密切相关[1].我们需要使用大数据的科学手段来有效地分析统计信息安全管理的重要性,以更好地满足时代发展的需要,逐渐和稳步推进医疗卫生行业的健康发展.

为实现对医院从业者日常出勤情况的严格把控,避免"误签""漏签""代签"等行为对常规人员监管造成的影响,设计了基于BSC评价方法的医院绩效考核软件.在关系网框架中选取固定考核指标,通过分析信息主体适应性的方式,构建外部考核体系.分析部门考核用例图,借助必要的绩效管理模块,连接用于成绩数据存储的数据库结构,完成基于BSC评价方法的医院绩效考核软件设计.对比实验结果表明,与传统医院考核制度相比,应用新型绩效考核软件后,个人出勤信息的记录时长提升至25天,代替打卡行为的出现几率也明显降低,可从根本上解决医院对从业者日常出勤情况把控不严格的问题.

综述脑卒中后疲劳(PSF)评估工具的制定及使用情况,介绍目前国内外常用的几种评估量表,并简单阐述其异同,为临床应用选择提供参考依据.

目的:分析卒中急救护士岗位的设立对急性缺血性卒中患者救治效果的影响.方法 :选取某院2017年7月1日至2018年7月26日经急诊绿色通道收治入院的107例急性缺血性卒中患者作为对照组,采用常规急救模式;2018年7月27日至2019年1月31日经急诊绿色通道收治的87例急性缺血性卒中患者作为实验组,采用卒中急救护士参与的卒中急救模式,比较两组患者的急救效率和关键质量指标差异.结果 :实验组进门到用药时间(Door-to-Needle-Time,DNT)中位数由52 min缩短至35.5 min(Z=-4.819,P<0.001);进门至股动脉穿刺时间(Door-to-Puncture-Time,DPT)中位数由87 min缩短至68.5 min(Z=-4.406,P<0.001);影像学检查至用药时间(Imaging-to-Needle-Time,INT)中位数由33 min缩短至14 min(Z=-6.922,P<0.001);影像学检查至股动脉穿刺时间(Imaging-to-Puncture-Time,IPT)中位数由73 min缩短至55 min(Z=-4.586,P<0.001).实验组和对照组DNT达标率分别为95.2％ 和84.7％(χ2=8.993,P=0.003),DPT达标率分别为95.8％和65.7％(χ2=7.518,P=0.006).实验组在出院和发病3个月时改良Rankin量表(MRS)评分≤2分的比例高于对照组,差异有统计学意义(P<0.05).结论 :卒中急救护士的参与能提高缺血性卒中患者救治效率,改善患者预后.

Background: The fear of social and professional consequences is a significant barrier to medication error reporting among nurses. Although some studies have identified cultural factors as playing a significant role in medication error reporting, little is known about the mechanisms by which these cultural characteristics influence the relationship between patient safety emphasis and the fear of medication error reporting. Objectives: (1) Identify nurses' perceptions of patient safety emphasis, face-saving, power distance, and fear of medication error reporting; and (2) explore face-saving and power distance as the underlying mechanisms for cultural factors in the relationship between nurses' perceptions of safety emphasis and the fear of medication error reporting. Design: A cross-sectional, descriptive, and correlational design. Settings: Three tertiary teaching hospitals located in China, including one children's hospital and two adult hospitals. Participants: We recruited a total of 569 female registered nurses with at least one year of work experience. Most of the participants (73.8%) were junior nurses with mid-associate or associate degrees (55.4%). Methods: Participants completed four questionnaires, including Safety Emphasis subscales from the Safety Climate Scale, Face-Saving Scale, the Index of Hierarchy of Authority, and the Nurses' Fear of Medication Error Reporting. Results: The average scores of safety emphasis, face-saving, power distance, and the fear of medication error reporting were 20.27 (SD=2.36), 14.63 (SD=3.57), 17.36 (SD=3.49), and 18.92 (SD=4.20), respectively. There were no demographic characteristics associated with these variables, except education (B=-0.16, p = 0.013) and work experience (B= -0.14, p = 0.019), which were related to power distance. Face-saving and power distance were significant mediators that explained the effect of safety emphasis on nurses' fear of medication error reporting. The overall indirect effect for both mediators was statistically significant ( beta=-0.27, p<0.05). When we compared the specific mediators' indirect effects, face-saving was a more powerful mediator than power distance ( beta=-0.24 vs. beta=-0.04). These mediation effects remained after we adjusted for the effects of education and work experience on power distance. Conclusions: When nurses have a common cultural background, they tend to perceive similar barriers to medication error reporting. For this study, face-saving and power distance are the two most important cultural factors because they significantly influence the relationship between safety emphasis and the fear of medication error reporting among Chinese nurses. It may not be possible to develop a work culture that minimizes fears of medication error reporting without first addressing face-saving needs and power differences. (C) 2019 Published by Elsevier Ltd.

目的 构建ICU患者谵妄评估约束分级方案并探讨其临床应用效果.方法 运用德尔菲专家函询法构建ICU患者谵妄评估约束分级方案.采用方便抽样法,选择416例ICU住院患者为研究对象,按护理单元将其分为试验组214例、对照组202例.试验组采用ICU患者谵妄评估约束分级方案进行谵妄评估及约束;对照组采用加拿大ICU约束决策轮及等级工具进行约束指导.结果 比较两组总约束时间、各级约束时间、疾病转归等,差异具有统计学意义(P＜0.05).在患者满意度、非计划性拔管率、坠床/跌倒方面,差异无统计学意义(P＞0.05).结论 基于德尔菲专家函询法构建的ICU患者谵妄评估约束分级方案,可减少ICU患者的约束时间,降低患者身体约束率及约束强度,改善患者的预后,保障了患者的安全.

目的 探讨2种不同腹部加压对帕金森病合并体位性低血压的影响.方法 选择帕金森病合并体位性低血压患者40例,采用充气式腹带分别给予20 mm Hg(1 mm Hg=0.133 kPa)和40 mm Hg腹部加压,观察腹部加压后患者体位改变前后血压变化.△收缩压=平卧位收缩压-直立位收缩压;△舒张压=平卧位舒张压-直立位舒张压.结果 20 mm Hg腹部加压15s和3 min△收缩压和△舒张压较干预前明显降低(P＜0.01);40 mm Hg腹部加压15 s和3 min△收缩压和△舒张压较干预前明显降低(P＜0.05,P＜0.01).20 mm Hg腹部加压与40mm Hg腹部加压15s和3 min△收缩压与△舒张压比较,差异无统计学意义(P＞0.05).患者20 mm Hg腹部加压轻度不舒适28例(70.0％),中度不舒适6例(15.0％),重度不舒适6例(15.0％);40 mm Hg腹部加压轻度不舒适2例(5.0％),中度不舒适15例(37.5％),重度不舒适23例(57.5％);20 mm Hg腹部加压舒适度明显优于40mm Hg腹部加压,差异有统计学意义(P＜0.01).结论 短时间腹部加压可以有效预防直立位血压下降,对收缩压影响更为明显,2种腹部加压血压变化无明显差异,患者对20 mm Hg腹部加压更为耐受.

目的 总结1例前交通动脉瘤并发神经源性肺水肿患者的护理经验.方法 通过脉搏指示连续心排血量监测(PICCO)量化补液策略,细化出入量管理,合理应用血管活性药物,既保证了脑灌注又防止肺部的进一步损害;在保持呼吸道通畅的基础上,给予正确通气支持,及早落实康复措施,促进患者肺康复.结果 经过精心的治疗和护理,患者恢复良好,术后17 d转康复医院治疗.结论 针对该患者,通过PICCO指导容量管理,加强呼吸道护理,是改善预后的有效手段.

抗N-甲基-D-天冬氨酸受体(N-methyl-D-aspartate receptor,NMDAR)脑炎是近年来发现的一种自身免疫性脑炎.2010年许春伶等[1]报道国内第1例抗NMDA受体脑炎病例,其后成为神经病学的研究热点,并形成成熟的2016年国际自身免疫性脑炎诊断路径和标准[2-3].抗NMDA受体脑炎为自身免疫性脑炎的一种独立类型,其临床表现包括精神行为异常、认知障碍、近事记忆力下降、癫痫发作、言语障碍、不自主运动、意识水平下降和中枢性低通气等[4-5].抗NMDA受体脑炎临床表现复杂、进展快、病程长、病死率及病残率高,约75%的抗 NMDA 受体脑炎患者需要重症监护支持,给护理带来较大难度[6].本科室于2017年4月收治1例抗NMDA受体脑炎患者,经治疗和护理病情稳定出院,现将护理体会报道如下.

ObjectiveTo study the clinical efficacy of Kegel on fecal incontinence in patients with anal endoscopic microsurgery.Methods Totally 60 patients with anal endoscopic microsurgery were randomly selected by purpose sampling method from October 2013 to June 2016,and they were divided into the control group and the observation group according to the random number table method,with 30 cases in each group. Patients in the control group received routine care,while patients in the observation group was trained by Kegel exercises before and after surgery. Incidence of fecal incontinence,anal function excellent rate and duration of fecal incontinence were observed and compared between two groups.Results The incidence rate of fecal incontinence in the observation group was 3.3%(1/30),while that of the control group was 23.3% (7/30) (P=0.052). The postoperative duration of fecal incontinence in the observation group was (3.3±0.5) d,while that of the control group was (5.3±2.4) d (t=4.468,P<0.05). Four days after surgery,the number of patients with good anal function in evaluation in the observation was 28,while that of the control group was 22 (Z=-2.020,P<0.05). ConclusionsKegel exercises before and after anal endoscopic microsurgery can effectively improve patients' anal function and shorten the duration of fecal incontinence. This method is simple,practical and can be widely used.

Objective: This study aimed to investigate clinical diagnosis and treatment of Peripherally Inserted Central Catheter (PICC) related deep vein thrombosis. Materials and Methods: A retrospective study was performed for 19 cases of patients with concurrent upper extremity deep vein thrombosis after inserting PICC from August 2011 to December 2014 in our hospital. Results: There were 8 cases and 11 cases with PICC in the right upper extremity and left upper extremity, respectively. All 19 cases had swelling of the upper extremities and discomfort after activity, and 18 cases had varying degrees of pain after activity. By ultrasonography 18 cases were diagnosed with deep vein thrombosis and 1 case with suspected deep vein thrombosis. All 19 patients underwent the indwelling thrombolysis catheter-directed thrombolysis based on anticoagulation therapy, thrombolysis time was 2-6 (3.16 ± 1.10 d), including 16 cases (89%) at grade III thrombolysis and 3 cases (11%) at grade II thrombolysis. 17 patients (89.5%) were clinically recovered and 2 cases (10.5%) were improved, with a total efficiency of 100%. No serious complication was noticed during thrombolysis. After thrombolysis, four cases were diagnosed as phlebostenosis and received stent implantation treatment. During follow-up of 6-36 months, no cases had recurred thrombosis and post-thrombotic syndrome. Conclusion: PICC related deep vein thrombosis could be diagnosed by color Doppler ultrasonic with venography as a supplement. Catheter-directed thrombolysis technique is characterized by short thrombolysis time, safety and efficiency for the treatment of C related deep vein thrombosis.

目的:探讨新生儿脐带严重水肿时,采用脉冲压迫方法断脐的效果.方法:将120例脐带水肿新生儿随机分为观察组和对照组各60例.观察组脐带脉冲压迫后断脐,对照组直接断脐.比较两组断脐时间、脐带残端意外断裂和血肿发生率、断脐质量及术者满意度.结果:观察组断脐时间短于对照组(P<0.01),断脐质量优于对照组(P<0.05),脐带残端意外断裂发生率少于对照组(P<0.01),术者满意度高于对照组(P<0.01).结论:脉冲压迫应用于严重水肿脐带新生儿断脐结扎中,快速、安全、术者操作满意.

原发性高血压病不仅会引起心血管、肾、外周动脉等疾病发生,同时也增加中风和痴呆的患病风险,是目前导致死亡的首要因素之一[1-3]。降低血压能够减少高血压病所引起的上述风险[4],收缩压下降10 mmHg(1 mmHg=0.133 kPa)或舒张压降低5 mmHg能使冠脉事件和脑卒中发生率分别减少22%和41%[5]。但仅通过药物控制血压,其效果并不理想[6-7]。额外采用一些非药物的治疗方法,如戒烟[8]、减少盐摄入[9]、降低体质量、增加运动和改变饮食等已被证实能够帮助控制血压[10]。而自主呼吸锻炼( Voluntary breathing exercise,VBE)作为一种新的非药物辅助治疗方法,也受到越来越多的关注。调查显示,VBE是人们最常用的非药物方法之一,其在心血管疾病的患者中使用率高达12%[11]。现就VBE在原发性高血压病患者中的运用综述如下。

Objective:To evaluate the effect of implementation of diabetes education kitchen model for two weeks on diabetes controlling.Methods:Randomized controlled trials was designed and a total of 1 12 patients with dia-betes mellitus who volunteered to participate in this study were randomly divided into experimental group and control group,56 cases in each.The patients in control group received diet education by nursing personnel in o-ral,writing,pictures and other forms,while the patients in experimental group received diet education by nutri-tionist and other professionals taught themselves and lived cooking method.And then the blood glucose,body mass index (BMI)and diet score index were compared between groups and within groups after two weeks inter-vention.Results:The patients’all indexes were improved after intervention in two groups and the difference be-tween two groups were statistically significant (P <0.05).Conclusion:Diabetes education kitchen model have significant intervention effect for diabetes mellitus controlling.

Objective The study aimed to investigate the influence of head nurse's transformational leadership style on emotional labor and psychological empowerment of nurses.Methods Totally 851 staff nurses from four 3A hospitals were investigated with the Transformational Leadership Style Sub Scale of Multifactor Leadership Questionnaire,Psychological Empowerment Scale and Emotional Labor Scale.Results The head nurse's transformational leadership style scored (2.41±0.81).The psychological empowerment of nurses scored (3.27±0.47),its autonomy dimension scored (3.81±0.50),staying at medium level.The emotional labor of nurses scored (3.68±0.61),its deep acting dimension scored (4.67±0.76),which was above medium level.The indirect correlation coefficient between head nurse's transformational leadership style and emotional labor (r=-0.13) was far higher than direct correlation coefficient (r=-0.04).The psychological empowerment was the full mediation variable by which head nurse's transformational leadership style influence emotional labor of nurses.Conclusions Head nurse's transformational leadership style can enhance nurse's selfefficacy,cognition of work significance and work autonomy,so that nurse's deep acting and positive perception of emotional display can be increased,and nurse's emotional exhaustion and job burnout can be decreased to retain nurses.

Objective The purpose of this study was to explore the early experience of elderly patients who had the Percutaneous Coronary Intervention (PCI) for the second time due to coronary restenosis, so as to provide targeted nursing interventions. Methods Nine elderly male patients underwent the second-time PCI were interviewed by using qualitative research method. Results The main experiences of these patients were as follows: obvious emotional disorder, rational intellectual curiosity, purposeful behavior modification and eager to obtain support from the family and society. Conclusions Nursing care for elderly male patients after the second-time PCI should involve mental care, knowledge, behavior, and family and social support.

目的：探讨饮食干预加指压按摩对急性心肌梗死（A M I ）患者稳定期排便情况的影响。方法将60例患者分为干预组（n＝30）和对照组（n＝30），对照组给予常规护理，干预组在常规护理基础上给予饮食干预与指压按摩。结果干预组发生便秘5例，便秘发生率16．7％，对照组发生便秘者17例，便秘发生率56．7％，两组比较差异有显著意义（χ2＝10．33，P＜0．05）；干预组发生心力衰竭者1例，发生率3．3％，对照组发生心力衰竭者8例，发生率26．6％，两组比较差异有显著意义（χ2＝6．41，P＜0．05）；干预组没有死亡患者，对照组发生2例死亡，两组比较差异无显著意义（χ2＝2．07，P＞0．05）；干预组患者住院期间满意度优于对照组（χ2＝5．46，P＜0．05）。评估两组患者出院前1～3 d排便症状（排便困难、粪便性状、排便时间、排便频度、腹胀），各条目得分及总分比较差异有显著意义（P＜0．05），下坠、不尽感此条目显示无显著意义。结论常规护理基础上给予饮食干预、指压按摩，可改善AMI患者排便情况，降低便秘与心力衰竭的发生率，提高住院患者满意度，干预效果显著。

目的：探讨循序减压弹力袜对折刀侧卧位手术患者的血流动力学影响及护理的影响。方法：将接受折刀侧卧位手术的患者随机分为两组，对照组接受常规护理治疗，试验组在对照组的基础上加用循序减压弹力袜治疗。监测折刀侧卧位前、中、后患者的血流动力学变化；监测循序减压弹力袜后折刀侧卧位患者的血流动力学改变。检测两组的需要监测时的收缩压（ SBP）、舒张压（ DBP）、平均动脉压（ MBP）、心率（ HR）及中心静脉压（ CVP）变化。结果：对照组和试验组的血压均值差别有统计学意义（ P<0.05），与折刀侧卧位后即刻相比，血压均值差别有统计学意义（ P<0.05）。结论：循序减压弹力袜对折刀侧卧位手术患者的血流动力学产生有益影响，值得临床推广。

目的 应用现代岗位价值评价方法形成科学的临床护理岗位价值评估框架,为优化护理绩效管理、临床护士岗位配置,进而提高护理质量等提供依据.方法 经岗位分析和德尔菲专家咨询,构建临床护理岗位价值评估模型,在此基础上采用要素计点法确定各临床护理岗位相对价值得分和价值等级序列,据此确定各临床护理岗位的薪资等级和岗位配置.结果 临床护理岗位价值评估模型包含4个一级要素和16个二级要素.按要素计点法将临床护理岗位分为3个等级.255个临床护理岗位的相对价值得分在268.5～1000.0分,分布在15个价值等级序列中.应用该模型实施护理绩效管理2年后,我院护士的薪酬满意度达88.3％,较改革前提高近50％,护理质量检查合格率100％,护士轮岗匹配、晋级晋升和薪资调整有据可依.结论 要素计点法是科学、客观地进行护理岗位价值评估的重要方法,依此建立的临床护理岗位价值评估框架为护理绩效管理、护士岗位配置等提供了科学依据.