Chow Susan K Y, Wong Frances K Y, Chan Tony M F, Chung Loretta Y F, Chang Katherine K P, Lee Rance P L
School of Nursing, The Hong Kong Polytechnic University, Hong Kong, China.
J Clin Nurs. 2008 Apr;17(7B):260-71. doi: 10.1111/j.1365-2702.2007.02231.x.
To examine community nursing services for patients with cardiovascular diseases, chronic respiratory diseases and other general medical conditions, making the transition from hospital to home.
The original study design was a randomised controlled trial. This study is a secondary analysis of the hospital records documented by community nurses for the study-group patients.
The sample consisted of 46 subjects, randomly drawn from the main study group of the study.
The community nursing records were analysed using the Omaha System. Self-reported health status and readmission data were retrieved from the data base of the original study.
The three groups of patients experienced problems across the four domains in the Omaha System. Community nursing interventions did not differ greatly by disease groups. The primary purpose of home visits was observation, followed by treatment and procedures and health teaching. The community nurses in the study spent more effort providing health teaching to the respiratory group than to their counterparts. The outcome measures are self-reported health status and hospital readmission rates. For self-reported health status, significant differences were observed in the respiratory and cardiovascular group before and after community nursing services. For hospital readmission rate, no significant difference was found.
To improve the well being of chronically ill patients, a comprehensive home intervention programme, emphasising continuous needs of monitoring and case management, is fundamental to producing desired, measurable effects.
This paper adds the understanding of home-care services provided by community nurses to chronically ill patients. The scope of nursing services emphasises the significance of a positive, patient-centred, caring and appropriate client-practitioner relationship to improve the self-reported health of patients.
研究为心血管疾病、慢性呼吸道疾病及其他一般内科疾病患者提供的社区护理服务，以及这些患者从医院到家庭的过渡情况。
原研究设计为随机对照试验。本研究是对社区护士记录的研究组患者医院病历进行的二次分析。
样本由46名受试者组成，从该研究的主要研究组中随机抽取。
使用奥马哈系统分析社区护理记录。从原研究数据库中检索自我报告的健康状况和再入院数据。
三组患者在奥马哈系统的四个领域均存在问题。社区护理干预在不同疾病组之间差异不大。家访的主要目的是观察，其次是治疗和操作以及健康宣教。该研究中的社区护士对呼吸疾病组患者进行健康宣教的投入比对其他组患者更多。结果指标为自我报告的健康状况和医院再入院率。对于自我报告的健康状况，社区护理服务前后，呼吸疾病组和心血管疾病组存在显著差异。对于医院再入院率，未发现显著差异。
为改善慢性病患者的健康状况，一个强调持续监测需求和病例管理的全面家庭干预计划对于产生预期的、可衡量的效果至关重要。
本文增加了对社区护士为慢性病患者提供的居家护理服务的理解。护理服务范围强调了积极的、以患者为中心的、关怀且恰当的医患关系对于改善患者自我报告健康状况的重要性。
