Bixby M B, Konick-McMahon J, McKenna C G
University of Pennsylvania School of Nursing, Philadelphia, USA.
J Cardiovasc Nurs. 2000 Apr;14(3):53-63. doi: 10.1097/00005082-200004000-00008.
Elderly patients with heart failure present a tremendous challenge to the current health care system. Decreased length of hospital stay for patients with increased numbers of comorbid conditions and complex medication regimens contribute to a revolving door of rehospitalizations. Using a transitional care model designed to decrease rehospitalizations, advanced practice nurses (APNs) in an ongoing clinical trial provide discharge planning in the acute care setting with home follow-up by the same APN for a 3-month period. This article reviews three case studies to provide a view of the complex and challenging situations in which elders with heart failure live and the care provided by APNs using the transitional care model to guide their practice. Social, economic, and emotional factors overlay the illness in each of these cases. The APNs, with advanced knowledge of cardiac disease and research-based management, help the patients and their caregivers to prioritize information and take the appropriate actions, while coping with the complexity of their conditions and the challenges they face. Keeping these patients from returning to the hospital provides evidence of the success of this transitional model of care.
老年心力衰竭患者给当前的医疗保健系统带来了巨大挑战。合并症数量增加且药物治疗方案复杂的患者住院时间缩短，导致反复住院的恶性循环。在一项正在进行的临床试验中，高级实践护士（APN）采用旨在减少再住院的过渡性护理模式，在急性护理环境中提供出院计划，并在3个月内由同一名APN进行家庭随访。本文回顾了三个案例研究，以展现老年心力衰竭患者所处的复杂且具有挑战性的情况，以及APN使用过渡性护理模式指导其实践所提供的护理。在每个案例中，社会、经济和情感因素都叠加在疾病之上。具备心脏病高级知识和循证管理能力的APN，帮助患者及其护理人员对信息进行优先排序并采取适当行动，同时应对病情的复杂性和他们所面临的挑战。防止这些患者再次住院证明了这种过渡性护理模式的成功。
