家庭医生模式下老年慢性病护理管理体系的构建

Construction of nursing management system for chronic diseases of the elderly under family doctor model

[目的]以慢性病轨迹框架为依据,构建家庭医生模式下老年慢性病护理管理体系。[方法]在文献研究、质性访谈及研究小组讨论的基础上,通过德尔菲法对24名专家进行专家咨询建立指标体系。[结果]2轮专家咨询问卷的回收率均为100%,专家权威系数为0.92。形成的家庭医生模式下老年慢性病护理管理体系包括一级指标5项(病前阶段、始发阶段、稳定阶段、功能障碍阶段、临终阶段)、二级指标20项、三级指标98项。[结论]构建的家庭医生模式下老年慢性病护理管理体系具有科学性、全面性及临床实用性,可指导社区护士实施护理干预,为社区护理管理者制订老年慢性病签约家庭护理计划提供依据。

Objective:To construct the nursing management system for chronic diseases of the elderly under the family doctor model based on chronic illness trajectory framework.Methods:Based on the literature review,qualitative interviews and research group discussion,Delphi method was adopted for conducting expert consultation among 24 experts.Finally,the nursing management system for elderly chronic diseases under the family doctor model was formed.Results:The response rates of two rounds of expert consultations were 100%.The expert authority coefficient was 0.92.The final nursing management system for chronic diseases of the elderly under the family doctor model included 5 first-level indicators(premorbid phrase,onset phrase,stabilization phrase,dysfunction phrase,terminal phrase),20 second-level indicators and 98 third-level indicators.Conclusions:The established nursing management system for chronic diseases of the elderly under the family doctor model was scientific,comprehensive and clinically practical,which could guide nursing intervention conducted by community nurses and provide reference for community care managers to develop signed family care plan for chronic diseases.