摘要
目的:探索慢性肾脏病(CKD)管理专科护士在疾病管理的作用。方法:2010年起成立CKD慢性病管理中心,组建以肾科医生、肾脏专科护士和营养师为团队,建立规范,明确岗位职责,优化随访流程,开展多元化的健康指导,培养内行病人达到全程递进管理,利用信息化建立患者档案资料。结果:专科护士在慢性肾脏病的管理中,既增加了患者的随访率,也增加了患者的满意度,提高患者自我管理的意识和能力,提高患者生存质量,获得较好的临床效果,同时也提高了专科护士的影响力。结论:CKD管理专科护士作为健康促进者教给患者疾病管理相关知识,其角色和作用在疾病管理中的实践中显得尤为重要,更能从专科角度发现问题、分析问题及解决问题,为CKD患者提供了有效的帮助和延续护理,提高病人的疾病自我管理能力,延缓疾病的进展和恶化。
This study aimed to explore the role of specialist nursing in the management of chronic kidney disease（CKD）. Since the establishment of chronic kidney disease management center in 2010, a management team has been built involved kidney specialists, specialist nurses and dieticians in response to setting up standards, confirming responsibilities, optimizing follow-up systems, carrying out diversified health guidance, training patients as spacialists in the whole-process management, and establishing health records for kidney patients using informatization. Specialist nursing in CKD management increased the follow-up rate, improved satisfaction of patients, self-consciousness and ability of self-management and their quality of life, which achieved favourable clinical utility and impressed patients with the influence of specialist nurses. In conclusion, specialist nurses of CKD management, as health instructors, should teach theories about disease management, whose roles were especially important in the practice of disease management. They provided asisstance and constant nursing for CKD patients by pointing out, analyzing and addressing problems from specialist aspects, and helped improve patients＇ abilities of self-management to slow down the process of diseases and prevent them from disease exacerbation.
出处
《世界科学技术-中医药现代化》
2016年第6期985-988,共4页
Modernization of Traditional Chinese Medicine and Materia Medica-World Science and Technology
基金
国家中医药管理局行业专项(201007005):慢性肾炎蛋白尿和慢性肾脏病4期中医优化方案推广研究
负责人:刘旭生
科学技术部国家"十二五"科技支撑计划课题(2013BAI02B04):中医药治疗慢性肾脏病5期(非透析)的效果比较研究
负责人:刘旭生
广州市科学技术委员会专项课题(002):建设国家级科技思想库研究课题
负责人:邓丽丽
关键词
慢性肾脏病管理
专科护士
疾病管理
慢性肾脏病
Management of chronic kidney disease
nurse specialist
disease management
chronic kidney disease
