奥马哈系统在肝豆状核变性患者临床护理记录中应用的可行性研究

The feasibility study of the application of Omaha system in the clinical nursing records of patients with hepatolenticular degeneration

目的:评估奥马哈系统用于肝豆状核变性患者临床护理记录书写中的可行性。方法:回顾性分析86例肝豆状核变性患者的结构化护理记录单,交叉映射法与奥马哈系统进行映射,看其吻合程度。结果:提取描述患者护理问题、症状及体征的条目216条,与奥马哈问题分类系统的吻合度为90.3%;提取护理干预344条,与奥马哈干预系统吻合度为77.3%。结论:奥马哈系统可用来描述肝豆状核变性患者的临床护理问题及干预措施,但由于此疾病无法治愈及发展延续性护理的必要性,未来护理人员可以以奥马哈系统为基础,构建肝豆状核变性患者的延续性护理方案,实现从医院到家庭的良好过渡,进而提高其生活质量。

Objective:To assess the feasibility of the Omaha system for the writing of clinical care records for patients with hepatolenticular degeneration.Methods:A retrospective analysis of structured care records of 86 patients with Hepatolenticular Degeneration was retrospectively mapped with the Omaha subsystem to see how well they matched.Results:216 items describing the patient's nursing problems,symptoms and signs were extracted,and the coincidence degree with the Omaha System was 90.3%;344 nursing intervention items were extracted,and the coincidence degree with the Omaha intervention system was 77.3%.Conclusion:The Omaha system can be used to describe the clinicalcareissues and interventions of patients with hepatolenticular degeneration,but since the disease cannot be cured and the need to develop continuing care,future caregivers can build a continuous care plan for patients with hepatolenticular degeneration based on the Omaha system to achieve a good transition from hospital to family and improve their quality of life.