作　　者： (李京连）; (杨芳宇）; (吴瑛）; (邓婷）; (任幸）;

机构地区： 首都医科大学护理学院,北京100069

出　　处： 《中华现代护理杂志》 2017年第18期2357-2361,共5页

摘　　要： 目的了解北京市ICU谵妄管理现状，为促进ICU谵妄的临床管理提供借鉴。方法采用便利抽样方法选择北京市2所市属三甲综合医院的6个ICU科室作为调查对象，2016年6-9月运用现场调查方法对6个ICU科室的谵妄管理现状和管理效果进行调查。结果6个ICU科室均尚未制订完整的谵妄管理制度和标准化流程，也未系统化评估谵妄危险因素。患者出现谵妄的临床症状时，6个科室均依据临床经验进行判断，3个科室通过专科医生会诊，无科室采用评估工具进行评估，谵妄预防措施采用率为46．2％～76．9％，谵妄处理措施实施率为65．8％。在医务人员判断发生谵妄的38例病例中，对25例（65．8％）谵妄患者实施了处理措施。调查期间，6个ICU的谵妄患者为106例，发生率为30．8％，医务人员谵妄识别率为35．8％。结论ICU谵妄评估还需要常态化，针对谵妄的预防措施及处理措施运用还不充分和完善，谵妄的管理效果还需要进一步提高。 Objective To investigate the current status of ICU delirium management so as to provide reference for the clinical management of ICU delirium. Methods A total of 6 ICU units from two class Ⅲ grade A hospitals in Beijing were selected by convenient sampling. The spot investigation method was used to investigate the delirium management status and effect from June to September 2016. Results Six ICU units had neither developed a complete delirium management system and standardized process, nor systematically evaluated delirium risk factors. When delirium patients had symptoms, delirium was diagnosed according to the clinical experience in 6 ICU units, while specialist consultation was used in 3 ICU units. None of these units used any delirium screening tool. The delirium prevention rate was from 46.2% to 76.9%. The implementation rate of delirium treatment was 65.8%. Among 38 cases of delirium patients diagnosed by medical staff, 25 cases （65.8%） of which were treated. During the study, there were 106 cases of delirium patients; the incidence of delirium was 30.8% ; the delirium identification rate of medical staff was 35.8%. Conclusions The normalization of routine monitoring of delirium in ICU is necessary. Prevention and treatment for delirium is inadequate. The effect of delirium management needs to be further improved.

关 键 词： 重症监护病房 谵妄 临床管理 数据收集