以奥马哈系统为基础构建全髋关节置换术后患者医院—社区一体化随访模式的效果观察

发布时间：2018-03-27 09:16

本文选题：医院　切入点：社区　出处：《护士进修杂志》2016年05期

【摘要】：目的以奥马哈系统为基础构建符合我国国情的全髋关节置换术后患者从医院到社区的一体化随访模式的效果。方法结合我国医院、社区现状制订医院转介社区流程,以奥马哈系统为框架制订社区随访流程及随访表,选择2014年1月—2015年6月厚街医院收治并行全髋关节置换术、术后转介洪梅、厚街社区的患者63例,通过3次电话随访及1次家居随访对全部患者进行术后10项常见护理问题的前瞻性干预,并观察其效果。结果通过随访干预,患者生理领域的疼痛、神经-肌肉-骨骼功能、排便、排尿功能的认知、行为、状况在出院1个月末得到显著改善(P0.05);健康相关行为领域的营养、睡眠休息形态、自我照顾的认知、行为、状况在出院3个月末得到改善(P0.05);出院后1个月末突显社会心理问题,但随着随访次数的增加,社会心理问题的认知、行为、状况评分(KBS评分)增加;家居随访对环境领域的住所改善效果优于电话随访。结论医院—社区一体化随访模式符合我国现有医疗体制状况,能够将医疗资源分配最优化;奥马哈系统能够切实有效地指导全髋关节置换术后患者的社区随访实践,能够分析患者的护理问题,改善状况,动态监测结局变化,值得推广应用。
[Abstract]:Objective to establish an integrated follow-up model from hospital to community after total hip arthroplasty based on Omaha system. Using the Omaha system as the framework, the community follow-up procedure and the follow-up table were established. 63 patients were selected from January 2014 to June 2015 to receive total hip replacement in Houjie Hospital. 63 patients were referred to Hongmei and Houjie community after operation. Through three telephone follow-up and one home follow-up, all patients were treated with prospective intervention of 10 common nursing problems after operation, and their effects were observed. Results through follow-up intervention, pain in physiological field, neuromusculoskeletal function, and neuromusculoskeletal function were observed in all patients. The cognition, behavior and status of defecation and urination were significantly improved at the end of one month after discharge. At the end of 3 months after discharge, the condition was improved (P 0.05), and the psychosocial problems were highlighted at the end of one month after discharge, but with the increase of follow-up times, the scores of cognition, behavior and state of psychosocial problems increased. The effect of home follow-up was better than that of telephone follow-up in the environmental field. Conclusion the hospital community integrated follow-up model is in line with the existing medical system in China and can optimize the allocation of medical resources. Omaha system can effectively guide the community follow-up practice of patients after total hip arthroplasty, can analyze the nursing problems of patients, improve the situation, dynamically monitor the outcome changes, and it is worth popularizing and applying.
【作者单位】：广东省东莞市洪梅镇社区卫生服务中心;广东省东莞市厚街医院;广东省东莞市厚街镇社区卫生服务中心;
【基金】：广东省东莞市医疗卫生科技计划一般项目(编号:2015105101132)
【分类号】：R473.2

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