基于《护理措施分类》构建不同功能状态脑卒中偏瘫患者的护理方案

Establishment of nursing measures for patients with hemiplegia after stroke in various functions based on Nursing Interventions Classification

目的 确定符合脑卒中偏瘫患者个体功能的护理方案,包括患者所需的护理措施及护理活动,指导临床实践.方法 通过查阅脑卒中偏瘫患者循证指南及相关临床实践文献,结合偏瘫患者相应功能状态下所需的护理措施,以美国第6版《护理措施分类》为基础,编制不同功能状态下患者所需的护理措施和活动类目,形成专家咨询问卷;对8名临床专家进行预函询及评价,然后对30名临床护士和41名护理专家分别进行2轮专家咨询.结果 最终确定脑卒中偏瘫患者的护理方案包括20条护理措施和307条护理活动;入选护理措施条目的专家一致性为80％ ～ 100％;入选的护理活动条目的赋值均数为4.00 ～ 5.00分,变异系数为0.00～ 0.25.结论 最终确定的护理方案能够满足脑卒中偏瘫患者的护理需求,且较系统全面,利于交流,可用于指导临床护理实践.

Objective To identify the nursing interventions and activities for hemiplegic patients in various functions suffered from stroke,and guide clinical practice.Methods Review rehabilitation of evidence-based clinical practice and literature of hemiplegic patients,stroke patients in different functional states were continuously cared and recorded by a researcher.Nursing program was identified according to patients' functions and the sixth edition of Nursing Interventions Classification,8 experts were consulted by a questionnaire survey,which was based on the initial screened nursing interventions and activities,30 nurses and 41 experts were consulted then.Results The established nursing program included 20 interventions and 307 activities.80％-100％ nurses' opinions culminated in consensus on the selected interventions.The selected activities scored 4.00-5.00 in average,with the coefficient of variations ranging from 0.00 to 0.25.Conclusions The established nursing program is convenient to communication and could be a tool to guide the clinical nursing practice.