持续性腹膜透析患者的延续护理.pdfVIP

中国护理管理 特别策划·延续护理实践与研究进展 Special Planning 持续性腹膜透析患者的延续护理 ◆ 王惠琴 张凤英 金静芬 林丹妮   [ 摘 要] 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。 [ 关键词 ] 腹膜透析；患者；延续护理；满意度 [中图分类号] R47 Continuing care of Continuous peritoneal dialysis patients / WANG Hui-qin, ZHANG 长），腹膜透析 (Peritoneal Dialysis， Feng-ying, JIN Jing-fen, et al. // Nursing Department, The Second Affiliated Hospital of PD)专科护士3名，病房责任护士15名， School of Medicine, Zhejiang University, Hangzhou, 310009 China /// Chinese Nursing 医生1名（顾问）。延续护理小组隶属护 Management- 2012,12(9): 15-17 [Abstract] Objective:To summarize the continuing care of the 108 cases of peritoneal 理部，人员安排和变动均需上报护理部。 dialysis patients in order to provide evidences for improving the continuing care technology, PD 专科护士的入选条件为：在肾内科工 and increasing nursing work value. Methods: Through establishing the continuing care 作5 年及5 年以上，主管护师及其以上 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 职称，并具有较强的责任心；接受过国 outside the hospital to 108 discharged peritoneal dialysis patients by using telephone follow 内或省内PD 专科护士培训并考核合格， up, web-based health education, and nursing clinic. Results: After 2 years of practice, 掌握腹膜透析知识及护理技巧，具备评 patient compliance increased from 51.3% to 91.4%, and peritonitis rate dropped from 1/45 patient-months to 1/61 patient-months. There wer