护理标准化诊断在急性胆囊结石术后患者中的应用

Application of standardized diagnosis of nursing in patients with acute cholecystolithiasis

目的:总结急性胆囊结石患者的术后护理标准化诊断并实施针对性护理,探讨其应用效果。方法:将我院2014年11月~2016年11月收治的108例急性胆囊结石患者纳为研究对象,所有患者均急诊入院,根据患者情况采取急诊手术或择期手术,术后均征得患者及家属的知情同意,入组配合研究。将其根据手术时间编号,采用数字随机表法等分为对照组和观察组。对照组采用常规护理,观察组采用我院制定的急性胆囊结石患者术后护理标准化诊断操作规程对患者实施护理诊断,再根据护理诊断结果,制定针对性护理方案,并严格实施。比较两组患者护理目标的达成情况、自我护理能力及并发症情况。结果:对照组患者术后疼痛耐受、舒适感增加、正确咳嗽、有效健康宣教、生命体征稳定均明显低于观察组患者,组间比较差异有统计学意义(P<0.05);对照组患者对并发症的观察知识、术后注意事项、饮食及活动计划、引流管自我护理知识测评结果明显低于对照组患者,组间比较差异有统计学意义(P<0.05);观察组患者术后出血、胆瘘、黄疸、多器官综合征、感染等并发症发生明显低于对照组(P<0.05)。结论:对急性胆囊结石患者术后实施护理标准化诊断,并根据诊断结果采取针对性护理措施,可有效提高患者护理目标的达成,提高临床护理质量。

Objective：To summarize the clinical diagnosis and implementation of targeted care for patients with acute cholecystolithiasis and to explore their application effect.Methods：A total of 108 patients with acute cholecystolithiasis admitted in our hospital from November 2014 to November 2016 were enrolled in this study.All patients were admitted to the emergency ward in our hospital.According to the conditions of the patients,emergency surgery or elective surgery were conducted.After the surgery,both the patient and their family were agreed to participate in the study.According to the operation time,the patients were numbered and divided into control group and observation group using the digital random table method.The patients in the control group were treated with routine nursing.The observation group were nursed and diagnosed by using the standardized diagnosis procedure of the patients with acute cholecystolithiasis in our hospital.Then the targeted nursing program were formulated and carried out strictly according to the nursing diagnosis.Nursing goals,self-care ability and complications of the two groups were compared.Results：Postoperative pain tolerance,increased comfort,correct cough,effective health education and vital signs of the patients in the control group were significantly lower than those of the observation group and the difference between the groups was statistically significant（ P〈0.05）.The self-care knowledge evaluation results of observation knowledge of complications,postoperative attention,diet and activity plan and drainage tube in the control group were significantly lower than those of the observation group and the difference between the groups were statistically significant（ P〈0.05）.Postoperative bleeding,biliary fistula,jaundice,multiple organ syndrome,infection and other complications in the observation group were significantly lower than those of the control group（ P〈0.05）.Conclusion：To implement standardized diagnosis of nursing on patients with acute cholecystolithiasis and adopt the targeted nursing care measures according to diagnosis results can effectively improve the achievement of the nursing goals for the patients and improve the quality of clinical nursing.