专病签约式随访管理在糖尿病肾病患者中的应用  

Application of contract-based follow-up management of special diseases in patients with diabetes nephropathy

作　　者：董杨翠 李素华[1] 马琴[1] Dong Yangcui;Li Suhua;Ma Qin(First Department of Nephrology,Kidney Disease Center,the First Affiliated Hospital of Xinjiang Medical University,Urumqi 830000,China)

机构地区：[1]新疆医科大学第一附属医院肾脏疾病中心肾病一科,乌鲁木齐830000

出　　处：《中华现代护理杂志》2023年第25期3476-3481,共6页Chinese Journal of Modern Nursing

摘　　要：目的探索专病签约式随访管理对糖尿病肾病(DN)患者自我感受负担、自我管理行为及病情控制的影响。方法以2020年1月新疆医科大学第一附属医院联合社区建立DN签约式随访管理模式为分界点,将2018年7月—2019年9月新疆医科大学第一附属医院联合社区纳入研究并实施常规随访管理的50例DN患者作为对照组,将2020年1月—2021年3月纳入研究并实施专病签约式随访管理的50例DN患者作为观察组,均进行为期3个月的随访管理,比较两组患者干预前后的自我感受负担[自我感受负担量表(SPBS)]、自我管理行为(自制DN患者自我管理行为量表)、病情状态指标[空腹血糖(FBG)、餐后2 h血糖(PBG)、随机尿白蛋白/肌酐比值(UACR)]及护理满意度。结果干预3个月后,两组患者SPBS中的身体负担、经济负担、情感负担评分均较干预前降低,且观察组干预后SPBS中的身体负担、经济负担、情感负担评分低于对照组,差异均有统计学意义(P<0.05);干预3个月后,两组患者DN自我管理行为量表中的饮食管理、运动管理、血糖监测、血液透析护理、用药依从性评分均较干预前升高,且观察组干预后DN自我管理行为量表中的饮食管理、运动管理、血糖监测、血液透析护理、用药依从性评分高于对照组,差异均有统计学意义(P<0.05);干预3个月后,两组患者的FBG、PBG、UACR水平均较干预前降低,且观察组干预后的FBG、PBG、UACR水平低于对照组,差异均有统计学意义(P<0.05)。观察组患者的护理总满意度高于对照组,差异有统计学意义(P<0.05)。结论专病签约式随访管理可减轻DN患者自我感受负担,改善其自我管理行为,有助于更好地控制病情。Objective To explore the effects of contract-based follow-up management of special diseases on self-perceived burden,self-management behaviors and disease control in patients with diabetic nephropathy(DN).Methods Taking the establishment of DN contract-based follow-up management model by the First Affiliated Hospital of Xinjiang Medical University and the community in January 2020 as the dividing line,50 DN patients who were included in the study and implemented routine follow-up management from the First Affiliated Hospital of Xinjiang Medical University and the community from July 2018 to September 2019 were selected as the control group,and 50 DN patients who were included in the study and implemented contract-based follow-up management of specific diseases from January 2020 to March 2021 were selected as the observation group.All patients were followed up for 3 months.Self-perceived burden[Self-Perceived Burden Scale(SPBS)],self-management behaviors[Self-made Self-management Behavior Scale of Patients with DN],disease status indicators[fasting blood glucose(FBG),2 h postprandial blood glucose(PBG),urine albumin creatine ratio(UACR)]and nursing satisfaction were compared between the two groups before and after intervention.Results After 3 months of intervention,the physical burden,economic burden and emotional burden scores on the SPBS scale of patients of the two groups decreased compared to those before intervention,and the physical burden,economic burden and emotional burden scores on the SPBS scale of the observation group were lower than those of the control group after intervention,and the differences were statistically significant(P<0.05).After 3 months of intervention,the scores of dietary management,exercise management,blood glucose monitoring,hemodialysis care,and medication compliance in Self-management Behavior Scale of Patients with DN of patients in the two groups increased compared to those before intervention.Moreover,the scores of dietary management,exercise management,blood glucose monitoring

关 键 词：糖尿病肾病 专病签约式随访管理 自我感受负担 自我管理 病情控制 

分 类 号：R473.5[医药卫生—护理学]