Transitional care for a patient with chronic obstructive pulmonary disease

介绍了1例慢性阻塞性肺疾病患者延续 护理的具体实施过程及护理成效。主要护理干预为出院计划,出院后家庭访视、电话随访2个阶段,包括全面的护理评估、建立共同的护理目标、个性化的健康教 育、指导和咨询、治疗和程序、个案管理和监测,以及持续护理成效评价,关键是实施以循证为基础的标准化护理干预方案。 ||A case study was conducted to demonstrate the implementation and outcomes of a transitional care program for Chinese patients with COPD.The program had two phases:discharge planning,and post-discharge home visit and telephone follow up.Nursing intervention included comprehensive assessment,mutual goal setting,individualized health education,guidance and counseling,treatment and procedure,case management and surveillance,and continuous evaluation.The key to success is to implement standardized evidence-based intervention protocols in clinical care.