主管：国家卫生健康委员会
主办：国家卫生健康委医院管理研究所
中国科技核心期刊（中国科技论文统计源期刊）
中国科学引文数据库（CSCD）核心库期刊
《中文核心期刊要目总览》核心期刊

中国护理管理 ›› 2019, Vol. 19 ›› Issue (5): 647-651.doi: 10.3969/j.issn.1672-1756.2019.05.002

• 特别策划·护理质量改善实践 • 上一篇    下一篇

慢性肾脏病个案管理模式的构建及应用

石钰 陈艳 邓俊娜 彭红梅 李旺 何静   

  1. 陆军军医大学新桥医院肾内科，400037重庆市（石钰，陈艳，邓俊娜，彭红梅，李旺）；护理处 （何静）
  • 出版日期:2019-05-15 发布日期:2019-05-15
  • 通讯作者: 何静，硕士，主任护师，护理处总护士长，E-mail:hejing55571@163.com
  • 作者简介:石钰，硕士，主管护师，肾内科护士长
  • 基金资助:
    重庆市科委技术创新与应用示范项目（cstc2018jscx-msybX0056）；中国研究型医院学会护理分会2018临床护理研究课题（2018-20-11）

The construction and application of case management model to patients with Chronic Kidney Disease

SHI Yu, CHEN Yan, DENG Junna, PENG Hongmei, LI Wang, HE Jing   

  1. Xinqiao Hospital of the Army Military Medical University, Chongqing, 400037, China
  • Online:2019-05-15 Published:2019-05-15
  • Contact: E-mail:hejing55571@163.com

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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。

关键词: 慢性肾脏病；个案管理；护理门诊

Abstract: 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 from 46.7% 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.

Key words: Chronic Kidney Disease; case management; nursing clinic

中图分类号:  R47
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