摘要
目的:构建基于App"医院-社区-家庭"联动的2型糖尿病患者延续护理方案。方法:通过文献回顾、质性访谈初步构建基于App"医院-社区-家庭"联动的2型糖尿病患者延续护理方案,采用2轮专家咨询对方案进行可用性评鉴和调整,最终确定延续护理方案。结果:该延续护理方案以糖尿病专科护士为主导、以糖尿病App为媒介、以"医院-社区-家庭"联动为机制,干预内容包括出院前建立患者健康档案、综合性评估、制订出院计划、出院转介以及出院后健康监测和提醒、健康教育及咨询、健康随访、健康评估、会诊及转诊2个阶段。结论:本方案构建过程科学、可行,可实现对患者的连续性、个性化管理,促进"资源整合,优势互补"。
Objective:To construct an extended care programme for type 2 diabetes patients based on the App and"hospital-community-family"linkage.Methods:Through literature review and qualitative interviews,an extended care programme for type 2 diabetes patients based on the App"Hospital-community-family"linkage was initially constructed,and two rounds of expert consultation were used to evaluate the usability and adjust the program.Results:This extended care program is led by a diabetes specialist nurse,mediated by a diabetes App,and based on the mechanism of"hospital-community-family"linkage.The intervention included two stages:establishment of patient health records,comprehensive assessments,discharge plan formulation,discharge referrals before discharge,and health monitoring and reminders,health education and consultation,health follow-up,health assessment,consultation and referral after discharge.Conclusion:The construction process of this protocol is scientific and feasible,which can realize continuous and personalized management of patients and promote"integration of resources and complementary advantages".
作者
孙维禧
王艳梅
李萍
Sun Weixi;Wang Yanmei;Li Ping(Department of Nursing,Shihezi University,Shihezi 832000,China;Department of Nursing,Gongli Hospital,Pudong New Area,Shanghai 200135,China)
出处
《中国实用护理杂志》
2021年第26期2008-2015,共8页
Chinese Journal of Practical Nursing
基金
上海市浦东新区卫生系统重点学科建设项目(PWZxk2017-10)
上海市浦东新区公利医院人才培养计划(GLRI2018-01)。
