CAJ | 학술논문

目的：探索医护合作责任制护理模式在社区老年2型糖尿病患者管理中的作用，旨在为社区慢性病管理提供参考。方法采用方便抽样法，选取2012年10月—2013年10月在上海市闸北区彭浦新村街道社区卫生服务中心建立档案的老年2型糖尿病患者127例，通过医护合作责任制护理团队对其进行疾病相关情况问卷调查、团体教育、个案咨询与指导等糖尿病管理，并评价管理前后空腹血糖、餐后2h血糖、糖化血红蛋白的达标率，疾病相关知识知晓率，运动情况及并发症发生情况。结果患者管理后空腹血糖、餐后2h血糖、糖化血红蛋白达标率均高于管理前，差异有统计学意义(P<0．05)。患者管理后糖尿病症状、糖尿病诊断知晓率均高于管理前，差异有统计学意义(P<0．05)；而管理前后糖尿病并发症知晓率比较，差异无统计学意义(P>0．05)。患者管理前后运动频率、运动时间分布比较，差异均有统计学意义(P<0．05)。患者管理前后尿微量蛋白、视网膜病变发生率比较，差异均无统计学意义(P>0．05)。结论医护合作责任制护理模式有助于患者控制血糖、提高疾病相关知识知晓率、加强运动，可为社区慢性病管理提供一定的参考。
목적：탐색의호합작책임제호리모식재사구노년2형당뇨병환자관리중적작용，지재위사구만성병관리제공삼고。방법채용방편추양법，선취2012년10월—2013년10월재상해시갑북구팽포신촌가도사구위생복무중심건립당안적노년2형당뇨병환자127례，통과의호합작책임제호리단대대기진행질병상관정황문권조사、단체교육、개안자순여지도등당뇨병관리，병평개관리전후공복혈당、찬후2h혈당、당화혈홍단백적체표솔，질병상관지식지효솔，운동정황급병발증발생정황。결과환자관리후공복혈당、찬후2h혈당、당화혈홍단백체표솔균고우관리전，차이유통계학의의(P<0．05)。환자관리후당뇨병증상、당뇨병진단지효솔균고우관리전，차이유통계학의의(P<0．05)；이관리전후당뇨병병발증지효솔비교，차이무통계학의의(P>0．05)。환자관리전후운동빈솔、운동시간분포비교，차이균유통계학의의(P<0．05)。환자관리전후뇨미량단백、시망막병변발생솔비교，차이균무통계학의의(P>0．05)。결론의호합작책임제호리모식유조우환자공제혈당、제고질병상관지식지효솔、가강운동，가위사구만성병관리제공일정적삼고。
Objective To investigate the effect of physician-nurse collaborative team care mode in the management of elderly patients with type 2 diabetes in community. Methods Using convenience sampling method, we enrolled 127 elderly patients with type 2 diabetes who had health records in Pengpu New Estate Community Health Service Center of Zhabei District of Shanghai from October 2012 to October 2013. Disease -related questionnaire survey, group education, case consultation and other diabetes management were undertaken on the patients by the physician-nurse collaborative team. The standard-reaching rates of FBG, 2hPBG and HbA1c, the awareness rates of disease-related knowledge, exercise condition and the incidence rates of complications were investigated. Results The patients had higher (P<0. 05) standard-reaching rates of FBG, 2hPBG and HbA1c after management than those before management. The awareness rates of diabetic symptoms and the diagnosis of diabetes after management were higher than those before management ( P <0. 05 ) , while the awareness rate of the complication of diabetes had no significant change after treatment (P>0. 05) . The exercise frequency and the distribution of exercise time after management were significantly different from those before management (P<0. 05) . The incidence rates of microalbuminuria and retinopathy had no significant changes after management ( P >0. 05 ) . Conclusion Physician -nurse collaborative team care mode helps the patients with blood glucose control, improve the awareness rates of disease-related knowledge, promote exercise and provide references for the management of chronic diseases in community.