蔡丽丹 骆新友 林嘉豪 杨云 周丹

[摘要] 目的 探讨护士观察量表（NOSIE）联合Braden压疮危险评估量表在精神心理科住院患者压疮风险中的评估价值。 方法 选择2018年1～5月南方医科大学南方医院精神心理科新入院的患者90例，依据NOSIE评分情况分为轻度病情组（48例）和严重病情组（42例）。采用Braden压疮危险评估量表评估并比较两组病例并发压疮的风险情况，在采取相应护理措施干预后进一步比较两组病例实际发生压疮情况。 结果 严重病情组并发压疮的风险率高于轻度病情组，差异有统计学意义（P < 0.05）；经护理干预后两组病例压疮实际的发生率均明显低于其预测的风险率，差异有统计学意义（P < 0.05），但两组之间差异无统计学意义（P > 0.05）。 结论 联合NOSIE和Braden压疮危险评估量表可以有效评估精神心理科住院患者并发压疮的风险，有利于针对病情采取适当的护理措施。

[关键词] 压疮；精神心理科；护士观察量表；Braden压疮危险评估量表

[中图分类号] R473.74 [文献标识码] A [文章编号] 1673-7210（2018）10（b）-0145-04

[Abstract] Objective To investigate the value of nurses′ observation scale for inpatient evaluation （NOSIE） combined with Braden scale in pressure ulcer risk of inpatients in Department of Psychiatry and Psychology. Methods From January to May 2018， in Department of Psychiatry and Psychology， Nanfang Hospital of Southern Medical University， 90 newly admitted patients were selected， according to the NOSIE score， they were divided into mild condition group （48 cases） and severe condition group （42 cases）. The risk of pressure ulcer in two groups were evaluated and compared with Braden pressure ulcer risk assessment scale. After taking the corresponding nursing measures， the actual situation of pressure ulcer in two groups were compared. Results The risk rate of pressure ulcer in severe condition group was higher than mild condition group， the difference was statistically significant （P < 0.05）. After nursing intervention， the incidence rate of pressure ulcer in two groups was significantly lower than the risk rate， the difference was statistically significant （P < 0.05）， but there was no statistically significant difference in the incidence of pressure ulcer between two groups （P > 0.05）. Conclusion Combined application of NOSIE and Braden scale can effectively assess the risk of pressure ulcer in inpatients of Department of Psychiatry and Psychology. It is benefit to take appropriate nursing measures for the patients with the disease.

[Key words] Pressure ulcer； Department of Psychiatry and Psychology； Nurses′ observation scale for inpatient evaluation； Braden pressure ulcer risk assessment scale

壓疮又称为压力性溃疡，是基础护理工作中一个常见问题[1-2]。压疮在精神心理科的发生率相对低于其他危重症或慢性病住院患者较多的科室，但由于部分严重的精神心理疾病患者出现木僵、强迫体位、精神症状未有效控制时的保护性约束、拒食导致全身营养不良、合并躯体其他慢性病而长期卧床等原因，压疮仍时有发生。因此，针对压疮问题开展相应护理及预防工作也是精神心理科护士不可忽视的一项工作内容。做好压疮护理对减轻相关住院患者的痛苦与经济负担，促进患者的整体康复具有重要意义[3-4]。本研究在以护士观察量表……