关键词: 护理, 压力性损伤, 遗漏

Abstract: Objective To investigate the occurrence and causes of nursing omission in patients with pressure injury and high-risk patients. Methods Inpatients and nursing staff in our hospital from January 2011 to January 2012 were selected as the research objects. The nursing problems of patients with pressure injury and with high-risk pressure injury were recorded by random survey, including nurses′ understanding and completion of nursing elements for prevention and treatment of pressure injury, and nursing omission and errors. Results A total of 161 nurses and 359 patients participated in this study. The nursing staff who participated in the study varied between 26 and 30 years, with an average wage of 8.6 years （3~17 years）. The night shift was predominant （39.75%）, followed by the afternoon shift （33.49%） and morning shift （26.76%）. The largest proportion of the staff works at the Internal Medicine service （22.4%）, followed by Surgery （19.9%）, neurology department （16.1%） and Intensive Care Unit （11.2%）. The average length of stay was 7.25 ± 6.3 （2 ~ 47） days. The problems found in nursing records mainly included discharge education （25.77%）, suggestions for patients and their families to prevent stress injury （4.11%）, perfect pressure injury nursing （3.0%）, recording the risk factors of stress injury （2.9%）, how to do skin care/wound care in response and operation errors （16.32%）, and patients′ request for help in toilet （5.5%）. In clinical practice, the most common problems were the use of pneumatic mattress （36.92%）, clean and dry diapers （12.42%）, maintenance of patients′ daily hygiene （11.32）, proper fixation of drainage tube （11.15）, urinary incontinence and perineum dampness （10.13）. The main cause of nursing omission or error is the lack of human resources. Conclusion in patients with pressure injury risk or suffering from stress injury, nurses′ cognition and specific practice are different. The occurrence and reasons of nursing omission are caused by many factors. Conclusion In patients with pressure injury risk or suffering from pressure injury, nurses′ cognition and specific practice are different. The occurrence and causes of nursing omission are caused by many factors.

Key words: vitamin B complex tablets, montmorillonite powder, oral ulcer, methotrexate