古桂花

【摘要】 目的：研究护理标准化诊断在急性胆囊结石术后患者中的应用效果。方法：从笔者所在医院2016年9月-2018年9月收治的急性胆囊结石术后患者中抽选72例纳入研究，采用掷硬币法分为参照组和研究组，各36例。对参照组患者实施常规术后护理干预，对研究组患者则在护理标准化诊断基础上制定具有针对性的术后护理方案并予以实施，对比两组护理目标达成率、护理质量及患者术后并发症发生情况。结果：研究组各项护理目标达成率均高于参照组，各项护理质量评分也均高于参照组，且术后并发症发生率2.78%，低于参照组的11.11%，差异均有统计学意义（P<0.05）。结论：根据护理标准化诊断结果制定具有针对性的护理方案，并将该护理方案应用到急性胆囊结石患者的术后护理中，可以显著提高各护理目标的达成率，提升科室整体护理质量，并可有效降低患者术后并发症发生率。

【关键词】 护理标准化诊断; 急性胆囊结石; 术后护理; 护理目标; 护理质量

doi：10.14033/j.cnki.cfmr.2019.16.040 文献标识码 B 文章编号 1674-6805（2019）16-00-02

【Abstract】 Objective：To study the application effect of standardized nursing diagnosis in patients with acute gallbladder stone after operation.Method：A total of 72 patients underwent the operation of acute gallbladder stone from September 2016 to September 2018 in our hospital were selected in the study.According to the coin-flipping methods，patients were assigned to reference group（n=36） and study group（n=36）.The reference group adopted the conventional nursing intervention.Based on the standardized nursing diagnosis，the study group adopted the specific nursing regimens.The achievement rate of nursing objectives，nursing quality and postoperative complication rate were compared.Result：The achievement rate of nursing objectives in the study group was higher than that in the control group，and nursing quality scores were higher than that in the control group，the postoperative complication rate in the study group（2.78%） was lower than that in the reference group（11.11%），the differences were statistically significant（P<0.05）.Conclusion：According to the results of standardized nursing diagnosis to develop targeted nursing programs，and the nursing program is applied to the postoperative care of patients with acute gallbladder stone.It can significantly improve the rate of achieving nursing objectives，improve the overall quality of nursing in departments，and effectively reduce the incidence of postoperative complications.

【Key words】 Standardized nursing diagnosis; Acute gallbladder stone; Postoperative nursing; Nursing goals; Nursing quality

First-authors address：Yuancheng District Peoples Hospital of Heyuan City，Heyuan 517000，China

近年來，随着人们生活水平的提高，饮食习惯的改变，胆囊结石发生率呈不断上升趋势，日益威胁着人们的身体健康[1]。目前临床上主要采用腹腔镜胆囊切除术来治疗该疾病，可以在微创的情况下达到较好的治疗效果，但由于腹腔镜胆囊切除术毕竟属于侵入性操作，在术后如果护理不当，也容易导致患者出现出血、皮下气肿、胆瘘、黄疸、感染等术后并发症[2-3]，进而影响手术治疗效果和患者预后，因此对急性胆囊结石患者实施良好的术后护理十分关键。本文主要研究了护理标准化诊断在急性胆囊结石术后患者中的应用效果，现报道如下。

1 资料与方法

1.1 一般资料

从笔者所在医院2016年9月-2018年9月收治的急性胆囊结石术后患者中抽选72例纳入研究，同时排除严重心、脑、血管、肝、肾等疾病患者和精神障碍者[4]。……