肝移植患者护理结局分类系统的应用研究

doi:10.3761/j.issn.0254-1769.2024.22.005

摘要/Abstract

摘要：

目的将护理结局分类系统应用于肝移植患者术后护理中，并探讨其对临床护理记录质量的影响。方法采用便利取样法，选取浙江省某三级甲等综合医院2022年6月—12月和2023年3月—8月期间行肝移植手术的患者各44例，两组分别为实施前组和实施后组。回顾性分析实施前组的护理记录，实施后组则在2023年通过肝移植护理诊断-护理结局链接量表进行评分。实施后组在术后当日、术后3 d、术后7 d、术后14 d及出院当日对护理结局进行评分，并对5个时间点的评分结果进行统计分析，使用护理诊断、干预和结果质量测量工具比较两组护理结局分类的应用效果。结果对15项护理诊断的护理结局分类评分进行单因素重复测量分析，其中9项结果显示4个测量时间点持续改善，差异具有统计学意义（P<0.05）；护理结局分类实施后的护理病历质量总分、护理诊断和护理结局的记录质量评分均高于实施前，差异具有统计学意义（P<0.05）。结论护理结局分类系统可用于评价成人肝移植患者的术后健康状态和护理效果，具有较高的专科特异性且能改善护理记录质量。

关键词: 肝移植, 标准化护理术语, 护理结局分类, 围手术期护理

Abstract:

Objective To analyze the application of a nursing outcome classification system in postoperative nursing of liver transplantation patients and its influence on the quality of clinical nursing records. Methods A total of 44 patients who underwent liver transplantation in a tertiary A general hospital in Zhejiang Province from March to August 2023 were selected by convenience sampling method. According to the North American Nursing Diagnosis Association International-Nursing Outcomes Classification linked scale of liver transplantation，nurses used the five-level classification method to score and review the liver transplantation patients on the day after surgery，3d after surgery，7d after surgery，14d after surgery，and on the day of discharge. The nursing outcome classification scores at 5 time points were statistically analyzed. The nursing records of 44 patients with liver transplantation from June to December 2022 were retrospectively collected by convenient sampling，and 44 nursing records before Nursing Outcomes Classification application and 44 nursing records after Nursing Outcomes Classification implementation were measured by Quality of Documentation of Nursing Diagnoses，Interventions and Outcomes. Results The Nursing Outcomes Classification scores of 15 nursing diagnoses were analyzed by single factor repeated measurement，and 9 of them showed continuous improvement and significant difference at 4 measurement time points（P<0.05）. After Nursing Outcomes Classification implementation，the total score of nursing record quality，nursing diagnosis and nursing outcome record quality scores were higher than those before implementation，with statistically significant differences（P<0.05）. Conclusion The nursing outcome classification system can be used to evaluate the postoperative health status and nursing effect of adult liver transplantation patients. It has high specialty specificity and can improve the quality of nursing records.

Key words: Liver Transplantation, Standardized Nursing Language, Nursing Outcomes Classification, Perioperative Nursing

韩琳秋, 冯志仙, 万鹏夏, 沈鸣雁. 肝移植患者护理结局分类系统的应用研究[J]. 中华护理杂志, 2024, 59(22): 2723-2730.

HAN Linqiu, FENG Zhixian, WAN Pengxia, SHEN Mingyan. Application of a core care outcome classification system for liver transplantation patients[J]. Chinese Journal of Nursing, 2024, 59(22): 2723-2730.

图/表 4

表1 肝移植护理诊断-护理结局分类链接量表

Table 1 NANDA-NOC link scale for liver transplantation

表2 两组肝移植术后患者一般资料的比较

Table 2 Comparison of general data of 2 groups of patients after liver transplantation

表3 两组护理记录的护理诊断、干预和结果记录质量评分比较（分）

Table 3 Comparison of Q-DIO entries of 2 groups of nursing records before and after application（score）

表4 15项护理诊断的NOC评分的重复测量方差分析及事后检验（分，$\bar{x}±s$，n=44）

Table 4 Repeated measure ANOVA and post hoc examination of NOC scores for 15 nursing diagnoses（score，$\bar{x}±s$，n=44）

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