持续性腹膜透析患者的延续护理

Continuing care of Continuous peritoneal dialysis patients

目的:对108例持续性腹膜透析患者的延续护理进行总结、分析,以进一步完善持续性腹膜透析患者的延续护理服务。方法:建立以腹膜透析专科护士为主导的延续护理团队,制定针对持续性腹膜透析患者的个性化健康教育及出院后的居家护理计划,对108例出院后的持续性腹膜透析患者采取电话随访、基于网络平台的健康教育、门诊随访及家庭访视等方式开展院外延续护理。结果:经2年实践,患者的治疗依从性由51.3%上升至91.4%,腹膜炎发生率由1/45病人月下降为1/61病人月;有89例患者不同程度地回归了社会;患者对延续护理服务的满意度为97.2%。结论:延续护理服务为持续性腹膜透析患者提供了持续、不间断的护理,提高了其治疗依从性及满意度,降低了其腹膜炎的发生率,促进了其病情转归,同时也提升了护理工作的职业价值。

Objective：To summarize the continuing care of the 108 cases of peritoneal dialysis patients in order to provide evidences for improving the continuing care technology, and increasing nursing work value. Methods： Through establishing the continuing care team lead by PD specialist nurse, make the personalized health education and the home care plan after discharge for peritoneal dialysis patients; and provide continuing care outside the hospital to 108 discharged peritoneal dialysis patients by using telephone follow up, web-based health education, and nursing clinic. Results： After 2 years of practice, patient compliance increased from 51.3% to 91.4%, and peritonitis rate dropped from 1/45 patient-months to 1/61 patient-months. There were 89 cases of patients returned to society with varying degrees. Patients satisfaction with continuing care was 97.2%. Conclusion： The continuing care for patients improves patient compliance, reduces the incidence of peritonitis, and promotes the patients＇ health outcomes.