Pieper Barbara, Monahan Janean, Keves-Foster Mary Kathryn, Farner Julia, Alhasanat Dalia, Albdour Maha
Ostomy Wound Manage. 2017 Oct;63(10):42-47.
Nursing education research is lacking with regard to nursing care plans for patients who have a wound and use of the nursing diagnosis impaired skin integrity. The purpose of this quality improvement project was to inform teaching about nursing care planning for patients with wounds by examining what rst-year nursing students attending a fundamentals of nursing course in a Bachelor of Science in Nursing program included in a nursing process assignment when caring for an assigned patient who had an acute or chronic wound. Because they were in their clinical rotation, students had access to the patients' medical records to facilitate composing the care plan; they also could ask the patient for information. Assessment data were entered on a predetermined form based on Gordon's Functional Patterns. Using this information, students had to provide 3 possible diagnoses and select 1 upon which they developed the care plan intended to include patient description, wound description, dressing, and nursing diagnoses and impressions. The forms then were ana- lyzed for assessment completeness. Thirty-eighty (38) care plans completed by students were collected on patients that included 23 men and 28 African-Americans; mean age of the patients was 60.11 ± 14.17 (range 20-87) years. Wounds included 25 surgical incisions, 4 pressure ulcers/injuries, 7 "other" wounds, and 2 not identi ed. None of the students' assessments provided a detailed wound description. The most common wound descriptors were location (n =19) and drainage (n = 15). For 8 patients, students stated the wound was covered by a dressing. Thirty (30) nursing diagnoses were listed. The most common nursing diagnoses were impaired physical mobility or activity intolerance, impaired com- fort, impaired skin integrity, imbalanced nutrition, and risk for infection. These nursing students had beginning skills in patient and wound assessment and writing nursing care plans about patients with impaired skin integrity. Students need to increase their depth of wound assessment and need more experience planning care for patients with wounds.
在针对有伤口且使用“皮肤完整性受损”这一护理诊断的患者的护理计划方面，护理教育研究较为缺乏。本质量改进项目的目的是，通过检查护理本科课程中参加基础护理课程的一年级护理学生在护理指定的急慢性伤口患者时，在护理过程作业中纳入了哪些内容，为伤口患者的护理计划教学提供信息。由于学生处于临床轮转阶段，他们可以查阅患者的病历以协助制定护理计划；他们也可以向患者询问信息。评估数据基于戈登功能模式录入预先确定的表格。利用这些信息，学生必须提供3个可能的诊断，并选择1个来制定护理计划，该计划旨在包括患者描述、伤口描述、敷料以及护理诊断和印象。然后对这些表格进行分析以评估其完整性。收集了学生完成的38份针对患者的护理计划，这些患者包括23名男性和28名非裔美国人；患者的平均年龄为60.11±14.17岁（范围20 - 87岁）。伤口包括25个手术切口、4个压疮/损伤、7个“其他”伤口以及2个未明确的伤口。没有一名学生的评估提供了详细的伤口描述。最常见的伤口描述词是位置（n = 19）和引流情况（n = 15）。有8名患者，学生表明伤口覆盖有敷料。列出了30个护理诊断。最常见的护理诊断是身体活动能力受损或活动耐力下降、舒适度受损、皮肤完整性受损、营养失衡以及感染风险。这些护理学生在患者和伤口评估以及撰写皮肤完整性受损患者的护理计划方面具备初步技能。学生需要加深伤口评估的深度，并且需要更多为伤口患者制定护理计划的经验。
