【摘要】 目的探讨奥马哈系统语言用于乳腺癌根治术患者延续护理的适用性,为推进护理记录语言的标准化提供依据。方法采用内容分析法和交叉映射法,回顾性分析2018年9月至2019年3月于广东省肇庆市第一人民医院行乳腺癌根治术及术后在该院行辅助化疗的62例患者的护理文件记录,比较与奥马哈系统术语的吻合程度。结果在护理文件中共提取501条描述乳腺癌根治术患者问题及干预措施的语言作为分析单元,其中与奥马哈系统术语描述完全吻合406条(81.0%),部分吻合81条(16.2%),不吻合14条(2.8%)。结论奥马哈系统语言适用于乳腺癌根治术患者延续护理的全过程,并为其提供实践指导,但应用前需做适当改良和调试。更多还原

【Abstract】 Objective To explore the applicability of the Omaha system language in the continued care of patients undergoing radical mastectomy, and to provide a basis for advancing the standardization of the language of nursing records. Methods Content analysis and cross-mapping methods were used to retrospectively analyze nursing file records of 62 patients who underwent radical mastectomy and adjuvant chemotherapy in the First People’s Hosptial of Zhaoqing, Guangdong Province from September 2018 to March 2019. The degree of agreement with the Omaha system terminology was compared. Results A total of 501 pieces of language describing the problems and interventions of patients with underwent radical mastectomy were extracted from the nursing documents as the analysis unit, of which 406(81.0%) were completely consistent with the Omaha system term description, 81(16.2%) were partially matched, and 14 items(2.8%) were not consistent. Conclusion The Omaha system language is suitable for the whole process of continued care for patients undergoing radical mastectomy and provides practical guidance for them, but it needs to be modified and adjusted appropriately before application.更多还原