慢性心力衰竭专病护士团队的组建及实践

Establishment and practice of a nurse specialist team for patients with chronic heart failure

目的探讨专病护士团队在慢性心力衰竭患者治疗护理中的作用。方法将2017年6~12月收治的300例慢性心力衰竭患者作为对照组,实施常规治疗护理和出院后随访;2018年1~6月收治的300例慢性心力衰竭患者作为观察组,由专病护士团队针对患者进行评估、跟踪,筛查临床前期患者,对临床期患者制定个性化的健康指导和出院后的团队延续护理,帮助终末期患者选择合适的治疗方案、实施急救措施、心理支持及社会援助;同时重视质量控制和专病护士的考评和管理,协助心力衰竭治疗中心和示范基地的建设。于干预6个月后比较两组疾病自我管理能力评分、再住院情况,以及医护患满意度。结果干预6个月后,观察组疾病自我管理能力、患者对护理工作满意度显著高于对照组,再住院率和再住院时间显著降低和缩短(均P<0.01)。医生、护士对专病护士团队的工作满意度较高。结论专病护士团队针对慢性心力衰竭不同阶段进行分工分期管理,可以提高患者生活质量和临床结局,有利于护士职业发展。

Objective To explore the effects of a nurse specialist team for patients with chronic heart failure.Methods A total of 300 patients with chronic heart failure admitted from June to December 2017 were assigned into the control group,who received routine treatment,nursing care and follow-up,and another 300 patients admitted from January to June 2018 were included into the intervention group,who were managed by the nurse specialist team:the team screened,evaluated and followed up the patients who were at pre-clinical stage,made individualized health guidance and provided transitional care after discharge for patients at clinical stage,helped end-stage patients to choose appropriate treatment plans,implemented first aid measures,provided psychological support and social assistance,at the same time assisted the construction of heart failure treatment center and demonstration base,and attached importance to quality control and evaluation and management of nurse specialists.Six months later,the scores of disease self-management ability,re-admission rates and satisfaction with nursing service were compared between the two groups.Results Six months later,the scores of disease self-management ability and satisfaction with nursing service in the intervention group were significantly higher,and re-admission rates,length of later hospital stay were significantly lower and shorter,than the control group(P<0.01 for all).Doctors and nurses were quite satisfied with the specialists′job.Conclusion The nurse specialist team provided phased management to heart failure patients at different stages,improve the quality of life and clinical outcome of patients,and boost nurses′career development.