Cormier Tina, Magat Ofelia, Hager Suzy, Ng Fanny, Lee Miran
Sheldon M. Chumir Health Centre, Alberta Health Services, Calgary, AB.
CANNT J. 2012 Apr-Jun;22(2):36-41.
As frontline nurses, we know firsthand the many challenges of renal disease faced by our patients and the impact on their lives and their families. How can we help them cope with their illness? How can we improve their quality of life? How can we prevent the complications inherent to the disease? How do we know we are doing a good job? Where do we start? The purpose of this presentation is to showcase the global management of the hemodialysis (HD) patient. It provides a collaborative and systematic approach to assessing, implementing, evaluating and coordinating the physiologic and the psychosocial aspects of their care. It is a model of case management followed by the Southern Alberta Renal Program (SARP) in meeting the many and complex needs of our hemodialysis patients. The quality indicators, to name a few, that relate to the physiologic aspects of their care are dialysis adequacy and fluid removal, improved blood pressure (BP) control, maintenance and improved vascular access function, anemia, bone and mineral disease management, nutritional, and diabetes management. The psychosocial aspects of care encompass goals of care, residential support, transportation, and mobility programs in the community. There may be positive implications resulting from our practice that we believe would be invaluable in terms of improved patient care, increased adherence to therapeutic regimens, improved mortality and morbidity and overall enhanced quality of life. Moreover, better communication would possibly be fostered and wise and prompt use of resources may be a result. To date, we have not done studies to prove or disprove these outcomes.
作为一线护士，我们亲身了解患者所面临的肾脏疾病的诸多挑战，以及这些挑战对他们及其家人生活的影响。我们如何帮助他们应对疾病？如何提高他们的生活质量？如何预防该疾病固有的并发症？我们如何知道自己工作做得很好？我们从哪里开始？本次演讲的目的是展示血液透析（HD）患者的全球管理。它提供了一种协作性和系统性的方法，用于评估、实施、评估和协调患者护理的生理和心理社会方面。这是艾伯塔省南部肾脏项目（SARP）遵循的病例管理模式，以满足我们血液透析患者的众多复杂需求。与他们护理的生理方面相关的一些质量指标包括透析充分性和液体清除、改善血压（BP）控制、维持和改善血管通路功能、贫血、骨和矿物质疾病管理、营养以及糖尿病管理。护理的心理社会方面包括护理目标、住宿支持、交通以及社区中的移动项目。我们的实践可能会产生积极影响，我们认为这些影响在改善患者护理、提高对治疗方案的依从性、降低死亡率和发病率以及全面提高生活质量方面将是非常宝贵的。此外，可能会促进更好的沟通，并且可能会明智而迅速地利用资源。到目前为止，我们尚未进行研究来证明或反驳这些结果。
