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

摘要： 目的 调查压力性损伤患者及高危患者的护理遗漏的发生和原因。方法 选择2018年1月到2019年1月在我院各专科住院的患者和相关护理人员为研究对象,以抽查性调查方式记录我院压力性损伤患者及有高危压力性损伤患者存在的护理问题,包括护理人员对预防和治疗压力性损伤护理要素的认识和完成情况,住院病人预防和处理压力性损伤的护理执行情况和差错。结果 共有161名护士和359例患者参与。参与研究的护理人员年龄在26至30岁之间,平均工资年限8.6年（3~17年）。收集数据的时间以夜班检查为主（39.75%）,其次是早班（35%）和下午班（22%）。调查的患者例数最大比例为内科（23.6%）,其次依次是外科、神经科、重症监护病房（分别为19.1%、17.4%、14.6）。患者平均住院时间7.25±6.3（2~47）天。护理记录发现的问题主要包括患者出院教育（25.77%）、向患者和家属提供预防压力性损伤的建议（4.11%）、完善的压力性损伤护理（3.0%）、记录压力性损伤的易发因素（2.9%）;回答和操作错误是如何皮肤护理/伤口护理（16.32%）、患者要求帮助如厕（5.5%）。临床实际操作中,出现最多问题（未执行或执行不当的护理项目）包括气动床垫的使用（36.92%）、尿布干净干燥（12.42%）、维护患者的日常卫生（11.32%）、固定引流管得当（11.15%）、尿失禁会阴部潮湿（10.13%）。导致护理遗漏或差错的的主要原因是人力资源的不足。结论 压力性损伤风险或患有压力性损伤的患者中,护士们的认知和具体实践存在差异,护理遗漏的发生和原因由多方面因素所然。

关键词: 护理, 压力性损伤, 遗漏