基于App"医院-社区-家庭"联动的2型糖尿病患者延续护理方案的构建  

Construction of continuing nursing program for type 2 diabetes patients based on App and"Hospital-Community-Family"linkage

作　　者：孙维禧 王艳梅[2] 李萍[1] Sun Weixi;Wang Yanmei;Li Ping(Department of Nursing,Shihezi University,Shihezi 832000,China;Department of Nursing,Gongli Hospital,Pudong New Area,Shanghai 200135,China)

机构地区：[1]石河子大学医学院护理系,832000 [2]上海市浦东新区公利医院护理部,200135

出　　处：《中国实用护理杂志》2021年第26期2008-2015,共8页Chinese Journal of Practical Nursing

基　　金：上海市浦东新区卫生系统重点学科建设项目(PWZxk2017-10);上海市浦东新区公利医院人才培养计划(GLRI2018-01)。

摘　　要：目的:构建基于App"医院-社区-家庭"联动的2型糖尿病患者延续护理方案。方法:通过文献回顾、质性访谈初步构建基于App"医院-社区-家庭"联动的2型糖尿病患者延续护理方案,采用2轮专家咨询对方案进行可用性评鉴和调整,最终确定延续护理方案。结果:该延续护理方案以糖尿病专科护士为主导、以糖尿病App为媒介、以"医院-社区-家庭"联动为机制,干预内容包括出院前建立患者健康档案、综合性评估、制订出院计划、出院转介以及出院后健康监测和提醒、健康教育及咨询、健康随访、健康评估、会诊及转诊2个阶段。结论:本方案构建过程科学、可行,可实现对患者的连续性、个性化管理,促进"资源整合,优势互补"。Objective:To construct an extended care programme for type 2 diabetes patients based on the App and"hospital-community-family"linkage.Methods:Through literature review and qualitative interviews,an extended care programme for type 2 diabetes patients based on the App"Hospital-community-family"linkage was initially constructed,and two rounds of expert consultation were used to evaluate the usability and adjust the program.Results:This extended care program is led by a diabetes specialist nurse,mediated by a diabetes App,and based on the mechanism of"hospital-community-family"linkage.The intervention included two stages:establishment of patient health records,comprehensive assessments,discharge plan formulation,discharge referrals before discharge,and health monitoring and reminders,health education and consultation,health follow-up,health assessment,consultation and referral after discharge.Conclusion:The construction process of this protocol is scientific and feasible,which can realize continuous and personalized management of patients and promote"integration of resources and complementary advantages".

关 键 词：APP 医院-社区-家庭联动 2型糖尿病 延续护理 方案构建 

分 类 号：R473.5[医药卫生—护理学]