慢性肾脏病个案管理模式的构建及应用
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摘要
目的 :构建慢性肾脏病个案管理模式并分析其应用效果。方法 :选拔与培训慢性肾脏病管理中心专职护士,完善专职护士岗位职责,开设护理门诊,构建并实施以护士为主导的慢性肾脏病个案管理模式。结果 :对2 763例慢性肾脏病患者实施了个案管理,患者规律随访率由47.4%增加至55.6%,优质低蛋白饮食达标率由21.2%增加至36.5%,吸烟率由41.3%降低至37.3%,周期性检查完成率由46.7%增加至50.3%,血压控制达标率由60.9%增加至64.1%,血脂控制达标率由46.9%增至51.4%(P<0.05);专职护士课题资助、发表论文、获得专利和获得护理新业务及新技术奖项数量明显增加。结论 :慢性肾脏病个案管理模式在临床的应用,提高了慢性肾脏病患者疾病管理水平,提升了护理质量。
Objective: To construct Chronic Kidney Disease(CKD) case management model and to analyze its clinical effect. Methods: Formed a nurse-led management model of CKD by selecting and traning specified nurses of CKD management center, modifying responsibility of specified nurses, opening nursing clinic. Results: Totally 2 763 CKD patients received case management. The follow-up rate increased from 47.4% to 55.6%, standard high quality low protein diet rate increased from 21.2% to 36.5%, smoking rate reduced from 41.3% to 37.3%, periodical examination rate increased from46.7% to 50.3%, blood pressure control rate increased from 60.9% to 64.1%, blood lipid control rate increased from 46.9%to 51.4%(P<0.05). The number of project grants, published papers, obtained patents, and awards gained by specified nurse increased significantly. Conclusion: The Case Management Model to CKD Patients in clinical practice, it improved the management level of CKD, improved the quality of specialized nursing, and promoted nursing quality.
Objective: To construct Chronic Kidney Disease(CKD) case management model and to analyze its clinical effect. Methods: Formed a nurse-led management model of CKD by selecting and traning specified nurses of CKD management center, modifying responsibility of specified nurses, opening nursing clinic. Results: Totally 2 763 CKD patients received case management. The follow-up rate increased from 47.4% to 55.6%, standard high quality low protein diet rate increased from 21.2% to 36.5%, smoking rate reduced from 41.3% to 37.3%, periodical examination rate increased from46.7% to 50.3%, blood pressure control rate increased from 60.9% to 64.1%, blood lipid control rate increased from 46.9%to 51.4%(P<0.05). The number of project grants, published papers, obtained patents, and awards gained by specified nurse increased significantly. Conclusion: The Case Management Model to CKD Patients in clinical practice, it improved the management level of CKD, improved the quality of specialized nursing, and promoted nursing quality.
引文
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[12]Sharma S,Sarnak MJ.Epidemiology:the global burden of reduced GFR:ESRD,CVD and mortality.Nature Reviews Nephrology,2017,13(8):447.
[13]Thomas R,Kanso A,Sedor JR.Chronic Kidney disease and its complications.Primary care,2008,35(2):329-344.
[14]Shi Y,Xiong JC,Chen Y,et al.The effectiveness of multidisciplinary care models for chronic kidney disease patients:a systematic review and Meta-analysis.International Urology and Nephrology,2018,50(2):301-312.
[15]石钰,邓俊娜,陈艳,等.Snyder希望理论模型在慢性肾病管理中的应用及效果评价.护理管理杂志,2017,4(17):283-286.Shi Y,Deng JN,Chen Y,et al.Evaluation of Snyder model used in the management of chronic kidney disease.Journal of Nursing Administration,2017,4(17):283-286.
[16]石钰,陈艳,陈学涛,等.互联网+专科护理门诊提高患者慢病管理水平.中国数字医学,2018,13(6):13-15.Shi Y,Chen Y,Chen XT,et al.Internet+specialist care outpatient improves the management level of chronic diseases of patients.China Digital Medicine,2018,13(6):13-15.
[17]陈艳,石钰,邓俊娜,等.以慢性肾病管理为主导的随访信息系统建立与应用.中国数字医学,2017,12(12):24-26.Chen Y,Shi Y,Deng JN,et al.The establishment and application of follow-up information system led by the management of chronic kidney disease.China Digital Medicine,2017,12(12):24-26.
[2]Wang J,Wang F,Saran R,et al.Mortality risk of chronic kidney disease:a comparison between the adult populations in urban China and the United States.PLoS One,2018,13(3):e193734.
[3]Zhang L,Wang F,Wang L,et al.Prevalence of chronic kidney disease in China:a cross-sectional survey.Lancet,2012,379(9818):815-822.
[4]Webster PAC,Nagler EV,Morton RL,et al.Chronic kidney disease.The Lancet,2016,389(10075):1238-1252.
[5]KDIGO.KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.Kidney International,2013,3(1):1-150.
[6]Lloyd A,Komenda P.Optimizing care for Canadians with diabetic nephropathy in 2015.Canadian Journal of Diabetes,2015,39(3):221-228.
[7]宋欣芫,郝洁,肖莉,等.护理专案改善在提高门诊慢性肾脏病患者自我管理能力中的应用研究.中华护理杂志,2017,52(6):692-697.Song XY,Hao J,Xiao L,et al.Application of nursing project in improving self-management ability of outpatients with chronic kidney disease.Chinese Journal of Nursing,2017,52(6):692-697.
[8]鲍云非,王红,周楚,等.慢性肾脏病一体化管理门诊患者的营养状况与饮食调查.中国血液净化,2017,16(3):154-157.Bao YF,Wang H,Zhou C,et al.A nutritional and dietary survey among CKD outpatients.Chinese Journal of Blood Purification,2017,16(3):154-157.
[9]Chen PM,Lai TS,Chen PY,et al.Multidisciplinary care program for advanced chronic kidney disease:reduces renal replacement and medical costs.Am J Med,2015,128(1):68-76.
[10]石钰,彭红梅,陈艳,等.慢性肾脏病患者自我管理类型与特点的聚类分析.中华现代护理杂志,2019,25(6):673-677.Shi Y,Peng HM,Chen Y,et al.Self-management types and characteristics of patients with chronic kidney disease:a cluster analysis.Chin J Mod Nurs,2019,25(6):673-677.
[11]Wouters OJ,O'Donoghue DJ,James R,et al.Early chronic kidney disease:diagnosis,management and models of care.Nature Reviews Nephrology,2015,11(8):491-502.
[12]Sharma S,Sarnak MJ.Epidemiology:the global burden of reduced GFR:ESRD,CVD and mortality.Nature Reviews Nephrology,2017,13(8):447.
[13]Thomas R,Kanso A,Sedor JR.Chronic Kidney disease and its complications.Primary care,2008,35(2):329-344.
[14]Shi Y,Xiong JC,Chen Y,et al.The effectiveness of multidisciplinary care models for chronic kidney disease patients:a systematic review and Meta-analysis.International Urology and Nephrology,2018,50(2):301-312.
[15]石钰,邓俊娜,陈艳,等.Snyder希望理论模型在慢性肾病管理中的应用及效果评价.护理管理杂志,2017,4(17):283-286.Shi Y,Deng JN,Chen Y,et al.Evaluation of Snyder model used in the management of chronic kidney disease.Journal of Nursing Administration,2017,4(17):283-286.
[16]石钰,陈艳,陈学涛,等.互联网+专科护理门诊提高患者慢病管理水平.中国数字医学,2018,13(6):13-15.Shi Y,Chen Y,Chen XT,et al.Internet+specialist care outpatient improves the management level of chronic diseases of patients.China Digital Medicine,2018,13(6):13-15.
[17]陈艳,石钰,邓俊娜,等.以慢性肾病管理为主导的随访信息系统建立与应用.中国数字医学,2017,12(12):24-26.Chen Y,Shi Y,Deng JN,et al.The establishment and application of follow-up information system led by the management of chronic kidney disease.China Digital Medicine,2017,12(12):24-26.