Research for the establishment of physical assessment practices at internal medicine wards and outpatient clinics

目的：确定内科病房护士身体评估项目的使用情况方法：在2005财政年度，研究采用参与式观察法，检查住院时的记忆和体温测量，以确定实际使用了哪些身体评估项目，研究对象包括一家区域中心医院（395张病床）内科病房（37张病床）的11名护士和同一病房处理的22例病例的医疗记录。在2006财政年度，向同一医院参加身体评估培训（2004年举行）的22名护士分发了问卷，随后对其中5名表示同意的护士进行了访谈。结果：13例患者采用了参与者观察法（8例回顾性调查，5例测温调查）。观察脑梗死2例，透析起始3例，高血糖/酸中毒1例，肾活检1例，不明原因发热1例。在记忆时，所有研究对象使用该设施的基本信息表对患者进行访谈，测量生命体征和血氧饱和度，并对水肿进行触诊。病历记录22例，其中肺炎10例，糖尿病4例，肾炎2例，SLE、脑梗死、肌营养不良、不明原因发热、肾病综合征、弥散性坏死性动脉周炎各1例。记录中的描述主要包括对基本信息表问题的回答、生命体征测量结果和日常生活活动的独立程度。在体能评估培训后，受访护士（平均年龄41.5岁）认为“呼吸”和“循环”系统的项目有用，而“肌肉-骨骼”、“神经”和“接受”系统的项目没用。他们还评论说，培训“增加了他们的知识”，“拓宽了技能范围”，“提高了观察病人的能力，更全面地看待病人”，同时也表示他们应该进一步培养准确掌握病人身体状况的能力。少

Purport : Identifying the usage status of physical assessment items among nurses at internal medicine wardsMethod : In the fiscal year 2005, the study used the participant observation approach to examine anamnesis and thermometry at hospitalization to identify what physical assessment items were actually used, covering 11 nurses working at the internal medicine wards (37 beds) of a regional hub hospital (395 beds) and medical records of 22 cases handled at the same wards. In the fiscal 2006, questionnaires were distributed to the same facility's 22 nurses who had taken part in the Physical Assessment Training (held in 2004), and five of them who consented were subsequently interviewed.Findings : The participant observation approach was used on 13 occasions (8 anamnesis occasions and 5 thermometry occasion). The observation covered 2 cases of cerebral infarction, 3 cases of dialysis initiation, and one case each of hyperglycemia / acidosis, renal biopsy and fever of unknown origin. At t … More he time of anamnesis, all study subjects used the facility's basic information sheet to interview patients, measuring vital signs and oxygen saturation, as well as conducting palpation for edema. Medical records of 22 cases covered 10 cases of pneumonia, 4 cases of diabetes, 2 cases of nephritis, and one case each of SLE, cerebral infarction, muscular dystrophy, fever of unknown origin, nephritic syndrome and disseminated necrotizing periarteritis. Description in the records mainly consisted of responses to questions in the basic information sheet, results of vital sign measurements and the extent of independence in daily life activities. After the Physical Assessment Training, surveyed nurses (with the average age of 41.5) cited items on the "respiratory" and "circulatory" systems as useful, while branding items on the "musculo-skeletal", "nervous" and "receptive" systems as not useful. They also commented that the Training "increased their knowledge", "broadened the range of skills" and "enhanced the observation skill to see patients in a more comprehensive approach", while also expressing that they should further develop the ability to accurately grasp patients' physical conditions. Less