奥马哈系统应用于脑卒中患者临床护理记录的可行性探讨  

Feasibility of applying the Omaha System to clinical nursing records of hospital stroke patients

作　　者：李文菁[1] 侯爱和[2] 毛建华 王慧荣[1] 蒋冬花[1] 肖亮[1] 

机构地区：[1]南华大学护理学院,湖南衡阳421001 [2]南华大学附属第一医院护理部 [3]常德市第三人民医院病案室

出　　处：《护理学杂志》2013年第19期13-15,共3页

摘　　要：目的探讨奥马哈系统应用于我国临床脑卒中患者的可行性。方法应用交叉映射法和分类法,回顾性分析57例脑卒中患者的护理记录单,提取护理记录上描述患者存在的护理问题、症状和体征以及护士采取的干预措施作为分析条目,考察其与奥马哈系统概念之间的匹配程度。每个条目分为完全匹配、部分匹配和不匹配3个等级。结果从脑卒中患者护理记录单中共提取371条描述患者存在的护理问题、症状和体征以及护理干预措施的记录,其中204条(55.0%)与奥马哈系统之间的概念完全匹配,152条(41.0%)部分匹配,15条(4.0%)不匹配。结论奥马哈系统可描述脑卒中患者住院期间的大部分问题、症状和体征及干预措施,可用于临床脑卒中患者的护理记录及描述,但应用时需对系统作适当的增删或修改。Objective To explore the feasibility of applying the Omaha System to clinical nursing records of hospital stroke patients. Methods We extracted items describing the nursing problems, signs and symptoms, and nursing interventions from nursing records of 57 stroke patients. Then they used the cross-mapping method and taxonomy to find out the conceptual congruence between the Omaha System and nursing records. The congruence was rated perfect match, partial match and not match at all. Results Totally, 371 sentences in nursing records of stroke patients were extracted to describe patientst nursing problems, signs and symptoms and nursing interventions. Of the 371 sentences, 204（55.0%） were labelled as ＂perfect match＂, 152（14.0%） as ＂partial match＂, and 15（4.0%） as ＂not match at all＂. Conclusion The Omaha System could describe most of patients＇ existing nursing problems, signs and symptoms and nursing interventions. It could be used in nursing records of hospital stroke patients. However, some amend- ments need to be made before application.

关 键 词：脑卒中 奥马哈系统 护理问题 症状 体征 匹配程度 

分 类 号：R473.5[医药卫生—护理学]