【摘要】目的研发连续性肾脏替代治疗(continuous renal replacement therapy，CRRT)护理信息化系统，旨在解决临床护理记录保存、资源共享、人力成本等问题，为患者提供安全优质护理。方法采用问卷调查、文献检索和会议讨论，优选CRRT 护理信息化系统所需信息项。从医院信息系统自动获取数据并进行解析、分类、可视化。通过问卷调查和质量管理，评价系统应用效果。结果CRRT 护理信息化系统共9 大类128 项，包括患者基本信息16 项、CRRT 治疗前护理评估20 项、调整医嘱执行6 项、用药医嘱执行17 项、CRRT 治疗过程中护理监测23 项、护理措施3 项、床旁血气分析20 项、出入量总结6 项、CRRT 治疗后护理评估17 项。与人工录入组相比，信息化组临床护理总时间明显缩短(t=29.305，P＜0.001)。结论CRRT 护理信息化系统能优化CRRT 护理流程，保障护理记录质量，提高工作效率，促进科研产出。
【Abstract】Objective The continuous renal replacement therapy (CRRT) nursing information system is designed to solve the problems of clinical nursing record preservation, resource sharing and human cost, and to provide safe and high quality care for patients. Methods The information items required in the CRRT nursing information system were selected by questionnaire survey, literature retrieval and conference discussion. These items were automatically obtained from the hospital information system, analyzed, classified and visualization. The application effect of this system was evaluated by questionnaire survey and quality management. Results The CRRT nursing information system contained 128 items organized into 9 categories, including 16 items of patients' basic information, 20 items of nursing evaluation before CRRT, 6 items of adjustment of medical orders, 17 items of medication orders, 23 items of nursing monitoring during CRRT, 3 items of nursing measures, 20 items of bedside blood gas analyses, 6 items of summary of intake and output volume, 17 items of nursing evaluation after CRRT. Compared with the manual record, the time spent on the CRRT nursing information system shortened significantly (t=29.305, P＜0.001). Conclusion CRRT nursing information system can optimize the CRRT nursing processes, ensure the quality of nursing records, improve work efficiency, and promote scientific research output.
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