顾娟 姚炯 申飞

[摘要] 目的 通过奥马哈系统在宫颈癌患者围术期护理中应用的可行性分析，旨在为该系统在宫颈癌患者全程照护领域中的适用性提供借鉴。 方法 回顾性分析2016年10月至2019年9月杭州市某三级甲等医院185例宫颈癌手术患者临床护理记录单，对比其描述条目与奥马哈系统条目之间的吻合程度。 结果 宫颈癌患者围术期护理记录中共提取383条描述患者的护理问题、症状和体征以及护理干预措施的条目，其中321条（83.8%）与奥马哈系统之间概念完全吻合，48条（12.5%）部分吻合，14条（3.7%）不吻合。 结论 奥马哈系统可用来描述宫颈癌患者围术期临床大部分问题、症状和体征及干预措施，能为宫颈癌患者围术期的护理评估和实践提供方向，适合作为我国宫颈癌患者围术期护理的标准化语言，但应用前需做适当调试和修改。

[关键词] 宫颈癌;奥马哈系统;标准化护理;护理

[Abstract] Objective To provide a reference for the applicability of Omaha system in the field of cervical cancer patients′ full-course care through the feasibility analysis of the application of the system in the perioperative care of cervical cancer patients. Methods The clinical nursing record sheets of 185 patients with cervical cancer surgery in a third-class A-level hospital in Hangzhou from October 2016 to September 2019 was retrospectively analyzed. The degree of agreement between the description items and the Omaha system items was compared. Results A total of 383 items describing the nursing problems， symptoms and signs， and nursing interventions of perioperative care records of patients with cervical cancer were extracted. Among them， 321 items（83.8%） completely matched the concept of the Omaha system， 48 items（12.5）% partially matched， and 14 items（3.7%） did not match. Conclusion The Omaha system can be used to describe most of the clinical problems， symptoms， signs and interventions of cervical cancer patients during the perioperative period. It can provide directions for the nursing evaluation and practice of cervical cancer patients during the perioperative period. It is suitable as standardized language for nursing during the perioperative period for cervical cancer patients in China， but proper debugging and modification are required before application.

[Key words] Cervical cancer; Omaha system; Standardized nursing; Nursing

宮颈癌居女性生殖系统恶性肿瘤的第一位，是女性常见恶性肿瘤，在发展中国家发病和死亡率达到85%[1-2]。据报告，大多数患者认为宫颈癌手术后将丧失性功能从而产生一系列的心理问题，如担心夫妻关系、家庭稳定等，使患者及其家庭承受各种压力[3-4]。宫颈癌患者易伴随生理、心理和生育功能障碍，给患者带来了极大伤害[5-6]。因医疗资源的不均衡、缺少对患者的规范干预措施和患者对宫颈癌相关知识的缺乏[7]，规范合理的护理评估和护理干预直接影响宫颈癌患者的疗效和康复[8]。奥马哈系统是北美护理协会认可的标准化护理语言，为护理人员的临床实践、护理评估和干预措施提供了指导和框架[9]。……