CAJ | 학술논문

目的：根据慢性肾脏病（ CKD）患者的特点和需求，探讨建立医院内CKD患者一体化护理模式，给患者提供持续完整的护理服务。方法成立CKD一体化护理小组，对2013年1—5月住院CKD患者的知识来源和疾病管理方式进行问卷调查，建立院内CKD护理转诊流程。结果150例患者对肾脏病护理知识了解情况中按患者得分情况依次为对自身疾病认识程度（4．41±1．11）分，对肾脏病知识了解程度（3．21±0．84）分，对疾病知识关注程度（2．75±1．30）分，疾病自我护理技术的掌握程度（1．39±0．83）分。分别有88．67％和60．00％的患者认为疾病信息来源于医护人员，但仍有大量患者从媒体、亲朋好友等处获得了不同的对疾病的认识。105例（70．00％）的患者希望定期门诊随访和教育得到疾病护理支持，位居第1位。经小组讨论初步建立院内一体化护理转诊模式，即针对目标患者进行转诊前护理和教育，配合转诊交接单一对一交接，转诊后护理和教育的模式。有81名护士参与流程运行并提出了改进建议。结论 CKD患者需要医护人员提供长期、连续、完整及个体化的护理和健康教育。建立院内CKD一体化护理转诊可能是解决这一问题的恰当方式。
목적：근거만성신장병（ CKD）환자적특점화수구，탐토건립의원내CKD환자일체화호리모식，급환자제공지속완정적호리복무。방법성립CKD일체화호리소조，대2013년1—5월주원CKD환자적지식래원화질병관리방식진행문권조사，건립원내CKD호리전진류정。결과150례환자대신장병호리지식료해정황중안환자득분정황의차위대자신질병인식정도（4．41±1．11）분，대신장병지식료해정도（3．21±0．84）분，대질병지식관주정도（2．75±1．30）분，질병자아호리기술적장악정도（1．39±0．83）분。분별유88．67％화60．00％적환자인위질병신식래원우의호인원，단잉유대량환자종매체、친붕호우등처획득료불동적대질병적인식。105례（70．00％）적환자희망정기문진수방화교육득도질병호리지지，위거제1위。경소조토론초보건립원내일체화호리전진모식，즉침대목표환자진행전진전호리화교육，배합전진교접단일대일교접，전진후호리화교육적모식。유81명호사삼여류정운행병제출료개진건의。결론 CKD환자수요의호인원제공장기、련속、완정급개체화적호리화건강교육。건립원내CKD일체화호리전진가능시해결저일문제적흡당방식。
Objective To investigate effect of the integrated care model based on patients′demand in in-charge patients with chronic kidney disease ( CKD) .Methods Established CKD integrated care team , and a questionnaire survey about knowledge and disease management was conducted in hospitalized CKD patients from January to May, 2013, and established the CKD care referral model in hospital .Results A total of 150 cases of hospitalized patients with CKD received a questionnaire .The scores of patients′awareness of CKD was (4.41 ± 1.11), and the knowledge about kidney disease was (3.21 ±0.84), and the degree of concern for knowledge of disease was (2.75 ±1.30), and disease self-care technology mastery was (1.39 ±0.83).88.67% and 60.00%patients considered disease knowledge received from healthcare professionals , but there were still a large number of patients received knowledge from the media , friends, etc.105 patients (70.00%) hoped to get nursing care of outpatient follow up and education .The integrated care referral pattern in hospital was initially established after team discussion which could provide targeted patients pre-referral care and education , coordinated with one by one referral patterns with one transfer form , post-referral care and education .There were 81 nurses joined the post-referral care and gave their suggestions .Conclusions CKD patients need long-term, continuous, complete and individualized health care and education .Establishment of integrated CKD care referral patterns may be an appropriate way to solve this issue .