关键词: 乳腺癌；个案管理师；淋巴水肿治疗师；医护联合门诊；康复

Abstract: To standardize the management of breast cancer patients, a rehabilitation clinic for breast cancer survivors was established in July 2018 and managed by a medical team composed of a surgeon and a nurse as breast cancer case manager. The surgeon was in charge of diagnosis and treatment while the nurse focused on rehabilitation records, limb dysfunction and lymphedema treatment and health education. For patients with limb dysfunction, the nurse was responsible for the assessment of shoulder joint mobility and individualized guidance of limb rehabilitation. The nurse as case manager also qualified as lymphedema therapist, who can evaluate the lymphedema status and implement comprehensive treatment. In 6 months, twenty-two patients with limb dysfunction were intervened, and showed significant improvement in the flexion and abduction of shoulder (P<0.05). Thirty-one patients with lymphedema were treated for 309 times totally, and the diameter of the affected arm and the unaffected arm were significantly decreased respectively (P<0.05). The rehabilitation clinic can carry out the comprehensive management of the breast cancer patients. The nurses as case managers play an important role during the whole process management of breast cancer patients.

Key words: breast cancer; case manager; lymphedema therapist; medical and nursing clinic; rehabilitation