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目的:构建经鼻肠内营养并发鼻黏膜压力性损伤风险预警分级标准及措施,为鼻黏膜压力性损伤的预防护理和监测提供参考依据。方法:基于文献回顾、小组讨论和专家函询以及层次分析等方法确立肠内营养并发鼻黏膜压力性损伤风险预警分级及干预方案。结果:2轮专家函询问卷的有效回收率分别为100%和94.4%,权威系数分别为0.900和0.916,专家意见协调系数分别为0.552和0.618,说明专家积极性较好,专家权威程度较高,专家意见逐渐趋于一致。指标权重的一致性检验值均<0.1,最终形成了包含4个一级指标(分级标准)及20个二级指标(处理措施)的干预方案。结论:研究构建的鼻黏膜压力性损伤风险预警分级标准及干预方案具有一定的科学性和合理性,有利于指导临床肠内营养并发症的预防及提高其护理质量。“,”Objective:To construct the risk classification criteria and intervention measures for nasal mucosal pressure injury due to enteral nutrition and to provide reference for the preventive care and monitoring.Method:A classification and intervention plan was established based on literature review, panel discussion, Delphi expert letter and AHP method.Results:The effective response rates were 100% and 94.4%, the expert authority coefficients were 0.900 and 0.916, and the opinion concordance coefficients were 0.552 and 0.618, respectively. It shows that experts have a good enthusiasm and a high level of expert authority, and the opinions of experts tend to be consistent gradually. Consistency tests of index weights were all <0.1. Finally, an intervention plan of enteral nutrition-related nasal mucosal pressure injury risk was established with 4 first-level indicators (grading standards) and 20 second-level indicators (treatment measures).Conclusion:The risk warning classification standard and intervention scheme of nasal mucosal pressure injury established in this study are scientific and reasonable, which is conducive to guiding the prevention of clinical enteral nutrition complications and improving the quality of care.