加護病房攝入／排出量記錄不完整改善專案

Project of Improvement of Decreasing ICU Intake and Output Records Incomplete

在加護病房中，護理人員必須評估紀錄護理活動情形，而其中病人所有的體液攝入／排出量，都需要測量及準確紀錄，因此，正確評估和紀錄排出量，是評估病人體液是否平衡的重要依據，也是醫師診治的重要指標，故引發此專案動機，期望藉由專案改善提升加護病房攝入／排出量記錄完整率。本單位於95年7月27日至95年8月5日統計單位內病人攝入／排出量記錄不完整率為60％，經分析後問題確立為：(1)攝入／排出量記錄未及時填寫(2)不清楚尿布、看護墊重量(3)人員不清楚紗布、棉墊重量(4)量杯刻度過大(5)人員不清楚攝入／排出量項目。故成立專案小組，針對問題進行改善重點包括：設計簡易攝入／排出量記錄板、增設磅秤、設計常用敷料重量對照表、增設多種不同刻度量杯、加強量杯刻度標示、修訂攝入／排出量記錄評核表。經由專案實施後，本單位病人攝入／排出量記錄不完整率由60％降低至5.9％。而經由此專案推動，也強化攝入／排出量記錄之完整性，提供醫護人員給液及補充電解質之指標，做為透析治療、脫水多寡之依據，有助臨床診治之參考。

In the intensive care unit, nursing personnel must evaluate and record nursing activities .There fore ,precise evaluation and recording volume, especially the patients fluid balance, is an important evidence. This can also help the physician in making a diagnosis. This precise recording mechanism was started in the hope of lowering and improving and incomplete recording methods of fluid balance in the ICU. The study period was from July 27 2007 to august 2007 the collected incomplete fluid balance record for in patients was 60.﹪after analysis the following problems were identified： 1.intake / output balance sheet not promptly and correctly filled. 2.uncertain manner of assessing the weights of diapers. 3.personnel are uncertain of the correct way of weighing gauges and dressings. 4.over-wide calibration of measuring instruments. 5.personnel are uncertain of what comprises correct fluid intake / output amount. After estabushing a special unit targeting these problems the following were implemented to increase the accuracy of recording:devise a simple fluid balance record sheet、increase number of weight instruments、devise a commonly used materials weights、devise various caubrated measuring cups、magnify the calibration on measuring cups、 revising the fluid balance sheet. After these measures were adopted the imprecise recording of fluid balance in the icu fell from 60﹪to 5.9﹪.This suggests that an accurate and complete fluid balance sheet can provide correct fluid and electrolyte balance diagnosis. This can also aid in hemodialysis therapy by estabushing a precise measure of the patient’s hydration status key words icu fluid input fluid output nursing records.