加護病房內患者身體約束護理記錄之改善方案

The Plan to Refine the Nursing Records of Physical Restraint for ICU Patients

加護病房住院患者的身體約束，是針對患者的生命安全與健康維護所需，在兼顧患者的人權與尊嚴之下不得已的醫護措施；其記錄之完善為護理品質維護中，不可或缺的一環。93 年1 至2 月本院內科加護病房的查檢結果，顯示身體約束記錄之完整性僅約30%。因而期望藉由PDCA 模式，加以探討並改善約束記錄之完整率，進而保障患者照護品質。我們發現約束記錄不完整的主要原因為：1.「記錄繁瑣不易達成」、2.「認為此項記錄不重要」、3.「記錄方式費時、不方便」；此三項共占全部影響因素的75%。針對要因我們擬定改善方案，包括：（1）. 制定身體約束的護理評估，以及（2）. 格式化的護理記錄單，以簡單化（simplicity） 與提醒（reminding）方式，配合積極宣導來進行改善。隨後的評估，發現改良的身體約束之護理記錄，其可行性與易接受性提升，而完整性亦達98% 以上。

For the sake of patients’ security and surviving, but to preserve the patients’human right, including beneficence, non-malfeasance, justice and autonomy, the nurses in the intensive care unit(ICU) sometimes had to afford certain physical restrain(s) to the patients .The nursing records hence need to be perfectly completed as could in order to achieve the best quality of nursing care in ICU .Unfortunately, we noted that the nursing records about the application of physical restraints on the ICU patients were not so perfect or complete during Jan and Feb, 2004; and, only 30% of the records were considered almost or nearly complete. In tracing the causes leading to such spots, we found there were several influencing factors; 75% of the nurses working in the ICU considered the record system“too complex to perform ”,“no so important”and“not so convenient and not so time-sparing”.We therefore reformed a formulated sheet with simplicity, but in a reminding model, for assessing and recording the nursing-care about the application of physical restraints on the ICU’s patients. We promoted the newly reconstructed system through intensive in-job and on-job training. And the nursing-care records for physical restraints in the ICU were completed in more than 98% thereafter.