目的:构建术后稳定期造口旁疝的临床预测模型,并进行内部验证和外部验证.方法:选取2013年10月——2019年12月上海市某三级甲等综合性医院739例肠造口病人作为建模集.采用问卷调查、查阅数据库和电话、网络随访等方式获取病人资料,基于竞争风险模型构建造口旁疝临床预测模型.使用Bootstrap重复抽样法对该模型进行内部验证.选取2020年1月—2020年12月120例肠造口病人作为验证集,对模型进行外部验证.采用C-统计量和ROC曲线下面积评价模型的区分度.结果:年龄、术后体质指数(BMI)、前列腺肥大、咳嗽、提举重物、造口腹带的使用、造口旁疝相关指导、腹肌锻炼以及体重变化是造口旁疝的独立影响因素,而糖尿病、造口性质、体力劳动、排泄情况接近临界值.术后稳定期预测列线图的C-指数为0.921,无论是内部抑或外部验证区分度均较为理想.结论:术后稳定期的造口旁疝临床预测模型能很好地预测造口旁疝的发生风险,能指导病人对自身情况实时评估,以便及时预防.

Objective:Based on the Delphi method, the electronic intelligent kanban system for general ward nursing was constructed, and its clinical application was studied.Methods:This study was the quasi experimental research, 39 nursing staff working in the experimental ward of electronic intelligent kanban in general surgery of Zhongshan Hospital Fudan University in November 2021 and November 2022 were selected, Delphi expert consultation was used to develop the menus and detailed contents of general ward nursing electronic intelligent kanban system, and it was used in clinical practice. We used the Chinese version of the Nursing Assessment of Shift Report to evaluate the effect of nursing staff before and after the application.Results:The authority coefficients of the two rounds of expert consultation were 0.868 and 0.886 respectively, and the Kendall coordination coefficients of expert consultation were 0.068 and 0.076 respectively (all P<0.01). Finally, the electronic intelligent kanban consisted of 4 first-level menus, 8 second-level menus and 13 third-level menus. After the application of electronic intelligent kanban, the score of Nursing Assessment of Shift Report increased from (79.62 ± 7.64) to (83.51 ± 2.47), with a statistically significant difference ( t=-3.03, P<0.05). Conclusions:The constructed nursing electronic intelligent kanban system was scientific and reliable, which will be beneficial to improve the the effect of nurse shift handover.

目的 检索、总结并评价国内外结肠镜检查前肠道准备的最佳证据.方法 系统检索国内外专业协会网站、指南网及数据库中关于结肠镜检查前肠道准备的最佳证据.检索时限为从建库至2020年11月30日.由2～4名研究者进行文献质量评价,并对纳入的文献进行证据提取.结果 最终纳入12篇文献,包括临床决策1篇,循证指南3篇,证据总结2篇,系统评价6篇.形成了肠镜检查前患者评估、健康教育、肠道准备方法、饮食调整、口服泻药、肠道准备质量评估及失败后补救措施等7个主题的19条证据.结论 患者肠镜检查过程中,护理人员、病区医生及内镜医生应密切合作,落实患者评估、健康教育、饮食及药物发放、肠道准备质量评估与反馈等相关措施,帮助患者完成高质量的肠镜检查.

目的 应用竞争风险模型评估肠造口旁疝(parastomal hernia,PSH)的发病风险及影响因素.方法 回顾性分析2015年至2019年735例行肠造口术患者的临床资料.通过Cox模型评估PSH的累计发生率.当死亡和回纳作为竞争事件出现时,采用Fine-Gray模型进行分析.结果 中位随访17.1个月,其间,136例(18.5％)发生PSH,PSH出现的中位时间为10个月.单因素Cox回归分析和单因素Gray检验显示,年龄、术前体质指数(BMI)、高血压、前列腺肥大、造口途径与PSH的发生相关.多因素Cox回归分析和多因素Fine-Gray模型均显示,年龄≥60岁、术前BMI≥25 kg/m2和经腹膜外造口术是PSH发生的独立影响因素.此外,多因素Fine-Gray模型显示,乙状结肠造口也是PSH的独立影响因素.使用Kaplan-Meier法分析发现,肠造口患者随访1年、2年和5年的PSH累计发生率分别为20.5％、29.8％和37.6％;使用Fine-Gray模型分析发现,肠造口患者随访1年、2年和5年的PSH累计发生率分别为13.69％、20.07％和25.31％.与Kaplan-Meier或Cox法相比,Fine-Gray模型对PSH累计发生率的估计始终较低.结论 在存在竞争风险的情况下,相比于Kaplan-Meier和Cox模型,Fine-Gray模型能更准确地评估与PSH发生相关的高危因素以及PSH的累计发生率.

目的 构建住院期间和出院后肠造口患者发生造口旁疝的临床预测模型并验证.方法 选取某三级甲等综合性医院2015年1月1日-2019年12月31日的735例肠造口患者,通过LASSO筛选预测变量,基于Cox比例风险回归模型构建预测模型,采用ROC曲线、校准曲线以及决策曲线分析(DCA)评价预测模型的预测效能.结果 (1)住院期间预测模型为h(x)=0.373 1×性别+0.794 6×年龄-0.311 0×支付方式-0.401 7×宗教信仰+0.048 0×教育程度+0.655 9×饮酒史+0.572 4×身高+0.681 4×术前 BMI+0.109 6×高血压+0.142 6×糖尿病+0.454 9×腹部手术-0.599 6×术前放疗+0.952 8×术前化疗+0.168 6×术前定位-0.523 6×手术时机-0.276 9×手术方式-0.045 7×造口部位+0.053 4×造口方式-1.019 1×造口性质+0.740 4×腹直肌.(2)出院后预测模型为h(x)=0.759 1×体力劳动+0.825 5×剧烈咳嗽-0.701 4×造口腹带-0.608 1×术后指导+0.587 4×术后化疗-0.036 6×术后放疗-1.871 4×排泄通畅-0.605 7×腹肌锻炼+0.585 7×术后体质量变化.住院期间灵敏度为0.639 5,特异度为0.734 6,约登指数为0.374 1;出院后灵敏度为0.854 5,特异度为0.801 5,约登指数为0.656 0.住院期间模型ROC曲线下面积为0.752 0;出院后模型为0.914 0.模型的验证结果显示:住院期间ROC曲线下面积为0.622 0,出院后为0.770 0,提示其预测效果较好.结论 肠造口患者造口旁疝临床预测模型能较好地预测造口旁疝的发生风险,能帮助临床医护人员及时筛选出高危人群,给予重点关注,并指导其重点预防.

目的:总结、评价结直肠术后病人加速康复外科出院标准的最佳证据,为临床实践提供参考.方法:计算机检索BMJ Best Practice、Up To Date、Canadian Anesthesiologists′Society官网、American Society of Anesthesiologists Committee官网、European Society of Anesthesiology官网、Joanna Briggs Institute Library、Cochrane Library、PubMed、EMbase、中国生物医学文献服务系统(CBM)、中国期刊全文数据库(CNKI)、万方数据库资源系统中的临床决策、指南、证据总结、最佳实践信息册、系统评价、系统综述、专家共识,对文献质量进行评价和资料提取,对符合质量标准的文献进行证据提取.结果:形成了包括出院时间、口服耐受性、肠道功能恢复、疼痛控制、活动与自理能力、临床检查、实验室检查、病人意愿、并发症风险和出院评估工具10个主题、16条最佳证据.结论:建议将口服耐受性、疼痛控制和充分活动、下消化道功能恢复、活动和自理能力、临床检查正常及相关实验室检查合格作为结直肠术后病人加速康复外科的出院标准.

Objectives: The aim of this implementation project was to improve nutritional screening and nutritional interventions for patients scheduled for gastrointestinal surgery in a general surgical ward. Introduction: Malnutrition is common in hospitalized surgical patients and has many adverse outcomes affecting the patients' quality of life. Improving nutritional risk screening and nutritional support could reduce the incidence of malnutrition and its adverse outcomes. Methods: The project used the JBI audit and feedback method to implement evidence into practice. JBI Practical Application of Clinical Evidence System and Getting Research into Practice audit tools were used for promoting change in general surgical wards. Six audit criteria were created based on an evidence summary, including using screening tool, patients' and caregivers' education, nurses' education on nutritional screening and support, preoperative nutrition support and postoperative early food intake. A baseline audit was conducted, followed by nursing information system improvement, education, multidisciplinary meetings targeted at clinicians and two cycles of follow-up audits. Results: Results from the baseline and follow-up audits showed improvement for all the criteria. Compliance for criteria 1-3 increased from 0 to 100%, and that for criterion 4 increased from 32 to 100%. These four criteria sustained 100% in follow-up cycle 2. Compliance for criterion 5 increased from 8 to 50% in follow-up cycle 1 audit, but decreased to 0% in follow-up cycle 2 audit, and similarly for criterion 6, compliance increased from 45 to 56% in follow-up cycle 1 audit, but decreased to 48% in follow-up cycle 2 audit. Conclusion: The objectives related to nutritional risk screening, nurse knowledge, patients and families were successfully realized and sustained positive results. This project demonstrated that a nursing information system and long-term patient education are essential strategies to achieve and sustain positive results. The objectives related to preoperative nutritional support and postoperative early enteral food intake were challenges and represented barriers. In future, a multiple-pronged strategy will be implemented to achieve overall success and change according to best practice.

Currently, surgery, usually supplemented with other adjunctive therapies, is the only potentially curative treatment modality for rectal cancer. There are tree common types of radical resection of rectal carcinoma: abdominoperineal resection (Miles procedure), low anterior resection (Dixon procedure) and Hartmann's procedure. This paper summarized the nursing management of a rectal cancer patient with skin mucous membrane separation after Hartmann's procedure. The enterostomal therapist carried out skin care, dressing management, home-based care and psychological care, in order to treat complications of enterostomy and improve the rehabilitation of the patient.

目的 促进最佳证据在消化道手术患者营养筛查与干预中的应用,以提高临床护理质量.方法 遵循JBI循证护理中心的临床证据实践应用系统(JBI-PACES)的标准程序与GRiP证据应用方法,基于2篇证据总结制定6条审查指标,进行证据应用前基线审查、证据应用和证据应用后2轮再审查.数据收集采用问卷调查及病例查阅的方式.结果 证据应用后,审查指标1～3依从率从0上升至100％,审查指标4由31.58％上升至100％,并在证据应用后第2次审查时仍维持在100％,差异有统计学意义.审查指标5依从率从8.33％上升至50.00％,而在证据应用后第2次审查下降至0％;审查指标6依从率从44.68％上升至56.25％,在证据应用后第2次审查下降至47.83％,差异无统计学意义.结论 最佳证据应用能够推动临床改革,信息化手段能够有效维持改革效果,多学科合作是证据应用的难点与挑战.

全球新型冠状病毒肺炎(COVID-19)疫情形势严峻,尚无特效治疗药物.为了降低重型和危重型COVID-19患者的病死率,复旦大学附属中山医院一线抗疫护理专家对重型/危重型患者的护理措施进行分析、探讨、总结,并结合有关文件规定和规范,制定本护理专家共识.

目的:对比研究加速康复外科术前患者口服果糖溶液的两种方法.方法:选取本院加速康复外科拟实施手术的患者80例,采用随机综合平衡法分为甲组(n=40)和乙组(n=40),两组均在术前晚9时后禁食,术前晚10时给予甲组果糖溶液1000mL,给予乙组400mL果糖溶液,另在术前晨5时给予200mL.对比两组术前术中的相关数据、术后并发症及胃肠功能恢复时间、住院时间.结果:术前甲组睡眠时间少于乙组(<0.05);术中乙组口渴、饥饿、低血糖发生率均低于甲组(P<0.05);术后两组均未发生并发症;甲组胃肠功能恢复时间及住院时间与乙组比较均有显著性差异(P<0.05).结论:对加速康复外科患者采用术前一天晚10时口服果糖溶液2瓶400mL,术前晨5时另口服200mL的方法更有优势,能够有效缓解患者口渴、饥饿感,促进其胃肠功能恢复,从而缩短住院时间.

镇痛、镇静是重症监护室（Intensive care unit ， IC U ）机械通气患者的基本治疗措施，有效的镇痛、镇静可提高患者舒适性，保证机械通气的有效性和安全性。但过度镇静会导致病人机械通气时间延长、呼吸机相关性肺炎发生率增高、深静脉血栓形成、病人医疗费用增加及住院时间延长［1］。研究［2］显示，机械通气患者每日中断镇静、实施每日唤醒，可防止过度镇静，缩短患者机械通气时间及IC U 入住时间。但每日间断镇静有增加患者自行拔管发生率的可能，并且使患者长期发生一些心理方面的并发症。因此，中断镇静、每日唤醒在临床上应用并不十分广泛。笔者通过系统检索相关证据并尝试将证据应用于临床机械通气患者，以探讨基于循证的每日中断镇静护理的临床适用性。

Objective:To summarize the nursing experience in the treatment of ischemic diseases of lower extremity by continu-ous arterial catheter-directed thrombolysis (CDT).Methods:From March 2010 to October 2014,99 patients with lower ex-tremity ischemic diseases were treated by continuous arterial CDT in Vascular Department,Zhongshan Hospital,Fudan Uni-versity.The routine nursing records were reviewed.The main nursing measures included the preoperative nursing of ischemic limb,postoperative nursing of thrombolytic catheter as well as the prevention and nursing of the complications.Results:A-mong the 99 patients accepted CDT treatment,there were 1 case of death resulted from septic shock,4 cases of amputation, while the ischemia situation of the remaining 94 patients were improved with good recovery.Conclusions:For the patients with ischemic diseases of lower extremity,taking reasonable and effective nursing measures in peri-operation period is one of the fac-tors to determine the efficacy of CDT.