Mayo Paula
University of Leeds School of Healthcare, University of Leeds, Leeds, England.
Nurs Stand. 2017 Oct 18;32(8):53-63. doi: 10.7748/ns.2017.e10968.
Accurate assessment of the acutely ill adult who has recently been admitted to hospital, or an inpatient whose condition begins to deteriorate, is becoming a required skill for nurses as people live longer and with a variety of complex conditions, and as nursing skills continue to evolve and develop. This article emphasises the importance of undertaking an accurate and comprehensive patient assessment to ensure that management strategies are implemented in a timely manner. The article also considers the importance of the National Early Warning Score (NEWS), which is a 'track-and-trigger' tool designed to identify patients who are at risk of deterioration. The presentation of shock is considered and how this can be identified using the NEWS. The patient assessment skills required by nurses are discussed and the main signs of patient deterioration, regardless of cause, are outlined. The article also examines the ABCDE (airway, breathing, circulation, disability and exposure) approach to assessment.
随着人们寿命延长且患有各种复杂病症，以及护理技能不断发展，准确评估刚入院的急性病成年患者或病情开始恶化的住院患者，正成为护士必备的技能。本文强调进行准确、全面的患者评估以确保及时实施管理策略的重要性。文章还探讨了国家早期预警评分（NEWS）的重要性，它是一种旨在识别有病情恶化风险患者的“跟踪与触发”工具。文中考虑了休克的表现以及如何使用NEWS来识别休克。讨论了护士所需的患者评估技能，并概述了无论病因如何患者病情恶化的主要迹象。文章还研究了评估的ABCDE（气道、呼吸、循环、残疾和暴露）方法。
