奥马哈系统应用于腮腺肿瘤患者围手术期护理的可行性

Feasibility Study on the Application of Omaha System on the Perioperative Period Nursing of Parotid Tumor Patients

目的:探讨奥马哈系统应用于腮腺肿瘤患者围手术期护理的可行性。方法:采用便利抽样法抽取118份腮腺肿瘤手术病历,采用归类法和交叉映射法分析患者护理记录与奥马哈系统中问题分类部分和干预措施组成部分的吻合程度,分析护理记录在奥马哈问题条目中的应用率及护理记录与奥马哈系统不吻合的内容。结果:在腮腺肿瘤118份病历记录内容中,与奥马哈问题系统、干预系统完全吻合的内容分别占64.43%、54.91%,部分吻合的内容分别占28.28%、23.08%,不吻合的内容分别占7.29%、11.01%,kappa系数值在问题系统为0.712,干预系统为0.765,研究者一致度较好;护理记录在奥马哈系统中应用率最高的领域为生理(22.95%),其次为社会心理和健康相关领域,环境领域最低;与奥马哈系统不吻合的护理记录内容占总内容的9.23%,问题分类主要有病房环境吵闹、面部神经功能损伤等,干预措施主要有晨晚间护理、绷带加压包扎的护理等问题。结论:奥马哈系统应用于腮腺肿瘤手术患者围手术期护理记录的吻合程度较好,可作为腮腺肿瘤围手术期患者的标准护理语言。

Objective： To investigate feasibility on the application of Omaha system on the perioperative period nursing of parotid tumor patients. Methods： Adopting convenience sampling to collect 118 case history of parotid tumor patients,classification and cross-mapping method to analyze agreement between nursing history and classification and intervention measures in Omaha system; analyzing application rate of issue entries in nursing history recorded by Omaha system,as well as the disagreement content between nursing history and Omaha system. Results： Of all the 118 parotid tumor patients ＇case history,total agreement content with Omaha system accounted for 64. 3%,partial agreement content 28. 28%,disagreement content 7. 3%; Kappa index value was 0. 712 in the system,intervention system was 0. 765,research consistency is good; highest application rate in the system concerning nursing history is physiology（ 22. 95%）,followed by social psychology and health related fields,envi-ronment related fields accounted the lowest; nursing history disagreement content accounted for 9. 23%of the total one in the system; issues classification showed raucous patients ward,facial nerve dysfunction; intervention measures were nursing in the morning and evening time,bandage wound compression and so on. Conclusion： The application of Omaha system on the perioperative period nursing of parotid tumor patients showed good agreement,which could be used as standard nursing language.