摘要
目的总结临床护士参与心力衰竭慢病管理的实践与体会。方法我院临床护士在心力衰竭慢病管理的发展趋势下,成立慢病管理护理服务团队,通过编制和发放自制《心衰患者自我管理手册》、与患者近距离交流、开展心力衰竭患者健康教育讲座和定期电话随访,为心衰患者讲解疾病知识、普及药物治疗知识和详解自我管理知识,建立心衰患者个人档案,电话随访了解慢性心衰患者的病情变化、用药情况、出入量统计及体重监测情况、饮食及心理状态,督促患者坚持居家自我管理,监督患者定期门诊复查。结果经心力衰竭慢病管理过的心衰患者再次复诊时会携带出入量和体重记录表,并准备好需要询问的问题,心衰患者出现状况时会主动打电话来询问护士解决方法,提高了心衰患者的积极性和自我管理意识。结论通过实施心力衰竭慢病管理工作,我们体会到心衰护理门诊的健康教育需求非常大,在实施心力衰竭慢病管理工作中存在诸多难点,参与心力衰竭慢病管理的护士需专科化。参与此项工作的护士体会到了心力衰竭慢病管理的意义。
Objective To summarize the experience of clinical nurses in the management of chronic heart failure.Methods Under the trend of the development of the management of chronic heart failure,Clinical nurse of our hospital established the nursing service team of chronic disease management the nursing service team.Through Compiling and issuing《Manual of self-management for patients with heart failure》、closing communication with patients、carrying out Health Education lectures for patients with heart failure and regular telephone follow-up,to educate patients with heart failure knowledge、popularize knowledge of drug therapy、detailed describe knowledge of self-management,establishing the personal files of patients with heart failure,telephone follow-up was conducted to understand the changes of the illness、medication situation、Statistics of inflow and outflow、weight monitoring、diet and psychological status of patients with chronic heart failure,Supervising and urging patients to adhere to self-management,supervising patients'regular outpatient review.Results Heart failure patients who have been managed for chronic heart failure by nurses will carry the statistics of inflow and outflow and weight when they come back for the second visit,and be prepared for questions to ask.PaHeart failure patients call their nurses and ask for solutions when they have problems.To a large extent,it improved the enthusiasm and self-management consciousness of patients with heart failure.Conclusion Through the implementation of the management of chronic heart failure,we realize that there is a great demand for health education in the outpatient department of heart failure nursing,and there are many difficulties in the management of chronic heart failure.Nurses involved in the management of chronic heart failure need to be specialized.The nurses involved in this work have realized the significance of the management of chronic heart failure.
基金
天津市胸科医院2018年院级课题(编号:2018XKZ13)。
关键词
心力衰竭
慢病管理
护理门诊
Heart failure
Chronic disease management
Nursing clinic
