奥马哈系统应用于肠造口患者的可行性研究  

The feasibility of applying the Omaha System to patients with colostomy

作　　者：陈飞[1] 张咏梅[1] 韦秀碧[2] 陈幸幸[3] 刘艾[3] 任娜娜[1] 

机构地区：[1]遵义医学院附属医院护理部,遵义市563000 [2]遵义医学院附属医院病案室,遵义市563000 [3]遵义医学院附属医院胃肠外科,遵义市563000

出　　处：《护理管理杂志》2015年第11期815-817,共3页Journal of Nursing Administration

摘　　要：目的探讨奥马哈系统应用于肠造口患者的可行性。方法采用内容分析法提取肠造口患者病历中描述护理问题以及干预措施的记录,通过交叉映射法分别比较提取的记录与奥马哈问题分类系统和干预系统之间的概念吻合程度。结果从141份肠造口患者的病历记录中共提取出4 401条护理问题和干预措施,其中1 740条(39.54%)记录与奥马哈系统的概念完全吻合,2 325条(52.83%)部分吻合,336条(7.63%)不吻合。护理问题的分布集中在生理领域,其次是健康相关行为领域、心理社会领域和环境领域;出现的护理措施涉及到奥马哈干预系统中所有干预方向的60.00%(45条)、干预类别的100.00%(4种)。结论奥马哈系统与肠造口患者病历记录的概念吻合度较高,可通过适当的调整应用于此类患者,指导其护理实践。Objective To explore the feasibility of applying the Omaha System to calostomy patients nursing. Methods Contentanalysis was used to extract sentences describing nursing problems and nursing interventions from the medical records of colostomy patients, and cross - mapping method was used to find out the conceptual congruence between the extracted sentences and problem classification scheme and intervention scheme from the Omaha system. Results Totally ,4 401 sentences were extracted including nursing problems and interventions form 141 ealostomy patients＇medical records. A total of 1 740 （ 39.54% ） were labeled as ＂perfect fit＂ ,2 325 （52.83%） as ＂partial fit＂ ,and 336 （7.63%） as ＂not fit at all＂ between medical record and concept in the Omaha system. The frequently reported problems were in physiological domain, then healthrelated behaviors domain, psyehosocial domain and environmental domain. The nursing interventions extracted accounted for 60.00% （45 sentences） of directions and 1（30.00% （4 kinds） of categories in intervention scheme from the Omaha system. Conclusion The conceptual congruence between the medical records of calostomy patients and the Omaha System is high, which indicats that Omaha System can be used for colastomy patients after appropriate adjustments to guide nursing practice.

关 键 词：奥马哈系统 肠造口 护理记录 吻合度 

分 类 号：R473.6[医药卫生—护理学]