以护理结局为导向的腰椎手术患者临床护理路径的构建

Construction of Nursing Outcome Oriented Clinical Nursing Pathway for Patients with Lumbar Spine Surgery

目的：完善腰椎手术患者临床护理路径，为患者提供规范化、科学化的护理服务模式，培养护士发现问题、思考分析问题及解决问题的能力，建立护士临床护理思维。方法以病历和文献回顾为理论依据，以科室现使用的临床路径为基础，查阅患者在手术不同阶段产生的主要护理问题与干预措施，结合《护理结局分类》形成针对性的腰椎手术患者结局评价指标。经过专家咨询与修改，形成符合腰椎手术患者的临床护理路径。结果构建了以护理结局为导向的腰椎手术患者住院当天、术前日、手术日、术后1～3 d、术后4～10d不同阶段的临床护理路径。结论以护理结局为导向的腰椎手术患者临床护理路径，集中了临床护理路径与护理程序的优势，实现了从个案管理到群体化护理，在使用过程中能充分反映不同层级护理人员的水平与资质，增加护士间的团队合作精神。

Objective To find out main nursing problems and to provide standardized nursing service for patients with lumbar spine surgery in different stages and to develop clinical nursing thought among nurses. Methods Nursing outcome evaluation indexes were identified with literature review as theoretical basis, clinical pathway and nursing process at present as the framework. Clinical nursing pathway for patients with lumbar spine surgery was then developed through expert consultation and the modification of indexes. Results Nursing outcome oriented clinical nursing pathway was constructed in different stages of lumbar spine surgery. Conclusion With the advantage of both clinical nursing pathway and nursing process, nursing outcome oriented clinical nursing pathway is beneficial to improving cooperation among nurses and satisfaction from doctors and patients.