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一种护理疼痛评估与记录信息系统:在肿瘤科的设计与应用

A Nursing Pain Assessment and Record Information System: Design and Application in the Oncology Department.

作者信息

Wang Pan-Feng, Shen Li-Qiong, Zhang Hong-Jun, Li Bao-Hua, Ji Hong

机构信息

Author Affiliations: Department of Radiation Oncology, Peking University Third Hospital (Ms Wang); Nursing School of Peking University (Ms Shen); Departments of Nursing (Ms Zhang) and Neurology (Ms Li) and Information Management Center (Ms Ji), Peking University Third Hospital, Beijing, China. Ms Shen has contributed equally with Ms Wang to this article as the co-first author.

出版信息

Comput Inform Nurs. 2017 Dec;35(12):647-652. doi: 10.1097/CIN.0000000000000373.

Abstract

Pain is an unpleasant sensory and emotional feeling accompanying existing, impending, or potential tissue damage. Valid pain assessment and standardized pain documentation are important in oncology pain management; however, they are still deficient. Thus, we developed a pain assessment and record information system for nurses in the oncology department and implemented a questionnaire survey to evaluate users' acceptance of the system. The pain assessment system focused on usability and efficiency to provide a modified workflow that was safe, less time-consuming, patient centered, enjoyable, and efficient. The pain assessment and record chart types in the system enabled greater standardization of pain assessments and records. The application of the system greatly improved the efficiency of nursing in the oncology department, guiding nurses in an accurate and comprehensive patient pain assessment and contributing significantly to further improvement in pain care standards and care decisions. Nurses and doctors surveyed reported a high degree of satisfaction with factors such as saving time and improving the capacity of pain control, suggesting that the system enhanced the quality of pain management. Through this system, we can promote pain management, improving care quality for patients.

摘要

疼痛是一种伴随着现存的、即将发生的或潜在的组织损伤而产生的不愉快的感觉和情绪体验。有效的疼痛评估和标准化的疼痛记录在肿瘤疼痛管理中很重要;然而,它们仍然存在不足。因此,我们为肿瘤科护士开发了一个疼痛评估与记录信息系统,并进行了问卷调查以评估用户对该系统的接受度。该疼痛评估系统注重可用性和效率,提供了一个经过改进的工作流程,该流程安全、省时、以患者为中心、令人愉悦且高效。系统中的疼痛评估和记录图表类型实现了疼痛评估和记录的更大标准化。该系统的应用极大地提高了肿瘤科护理效率,指导护士进行准确、全面的患者疼痛评估,并为进一步提高疼痛护理标准和护理决策做出了重大贡献。接受调查的护士和医生对节省时间和提高疼痛控制能力等因素表示高度满意,这表明该系统提高了疼痛管理质量。通过这个系统,我们可以促进疼痛管理,提高患者护理质量。

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