护士主导的专病一体化管理模式在腹膜透析患者随访中的应用

Application of nurse-led integrated specialized disease management model in the follow-up of peritoneal dialysis patients

目的腹膜透析作为可居家治疗的行为,目前缺乏动态规范的随访制度及出院后延续护理的专业管理队伍,与血液透析相比门诊随访质量较低,文中旨在探讨护士主导的专病一体化管理模式在腹膜透析患者随访中的应用效果。方法对2012年1月至2013年5月在我院全军肾脏病研究所行维持性PD治疗的270例慢性肾衰竭随访患者实施护士主导的专病一体化管理模式,采用自制疾病掌握程度调查表和自我护理能力测定量表评定患者自我护理能力、疾病知识的掌握程度变化情况,并定期随访。结果比较患者出院前1d和出院后1个月、3个月疾病知识掌握程度,显示出院后1个月的患者知识掌握程度高于出院前1d,出院后3个月高于1个月;接受护士主导的专病一体化管理模式后患者定期门诊随访率从78.3%提高至88.6%;患者出院前1 d和出院后1个月、3个月时自我护理能力不断提高,差异均有统计学意义(P<0.05)。结论护士主导的专病一体化管理模式可提高腹膜透析患者的自我护理能力,降低患者医疗费用,值得临床推广应用。

Objective Peritoneal dialysis can be done at home, however, its clinical follow-up quality is lower compared with hemodialysis due to the lack of detailed follow-up system and professional management team for post-discharge nursing care. The article aimed to explore the effect of a nurse-led integrated specialized disease management model in the follow-up of peritoneal dialysis patients. Methods Nurse-led integrated specialized disease management model was provided for 270 patients with peritoneal dialysis （PD） from January 2012 to May 2013. Self-designed questionnaire on diasease knowledge and self-care assement questionnaire were used for patients to evaluate their self-care ability and understanding of disease knowledge. Regular follow-up continued. Results The patients＇understanding of disease knowledge was on the rise at 1 st day before discharge, 1 st month and 3rd months after discharge. After the application of nurse-led integrated specialized disease management model, the patients＇regular clinical follow-up rate was increased from 78.3% to 88.6%. The patients＇ self-care ability improved gradually at 1st day before discharge, 1st month and 3rd months after discharge, which was of significant differences. Conclusion The nurse-led nurse-led integrated specialized disease management model can improve peritoneal dialysis patients＇self-care ability and reduce their medical expense, which is of clinical sig- nificance.