基于奥马哈系统分析访视护理个案记录的研究

目的了解社区被访视患者存在的常见问题及访视护士常采取的干预措施,为规范访视护理提供依据。方法采用内容分析法,按照奥马哈系统条目,回顾性分析178份访视个案记录。结果平均每例患者存在5.91个问题;99.44%的患者存在生理领域问题,69.10%的患者存在健康相关行为领域问题,37.08%的患者存在环境领域问题,28.65%的患者有社会心理领域问题。访视过程中社区护士最常采用的干预方向是膳食管理、症状/体征-身体、运动和药物管理等,分别占80.80%、67.90%、65.10%和52.20%;最常采用的干预方式是健康教育、指导和咨询,占94.30%,其次是监测、治疗和程序、个案管理,分别占70.70%,66.80%和13.40%。结论按照奥马哈系统的条目对访视患者存在的常见问题和访视护士常采取的干预措施进行归类,可以分析出社区访视护理存在的问题,并为护理计划的制定和标准化访视流程的形成提供依据。

A study on home visit documentation based on the Omaha system

Objective To identify the most common problems in community patients and the interventions used most frequently by visiting nurses during home visits,and to provide reference for regulating home visits.Methods By using content analysis,178 home visit documentation records were analyzed based on the Omaha system.Results Each patient averaged 5.91 problems.The percentages of patients with physiological problems,health related behaviors,environmental and psychosocial problems were 99.44%,69.10%,37.08% and 28.65% respectively.The interventions used most frequently by visiting nurses were dietary management,symptoms/signs-physical,exercises,and medication administration,with the rates being 80.80%,67.90%,65.10% and 52.20%;the most frequently used intervention fell into such categories as as teaching,guidance,and counseling (94.30%),surveillance (70.70%),treatments and procedures (66.80%),and case management (13.40%).Conclusion The Omaha system was found to be a valid and reliable tool to identify problems in community clients and interventions adopted by nurses,and to determine problems in home visits.It can provide information for making nursing plan and standardizing home visits.