老年护理敏感指标体系的构建及其在老年糖尿病患者延续护理中的应用.docx

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1、 南方医科大学 2012 级硕士学位论文 老年护理敏感指标体系的构建及其在 老年糖尿病患者延续护理中的应用 Design and Application of Geriatric Nursing Sensitive Indicator System in Transitional Care of Elderly Patients with Diabetes Mellitus 课题来源：广东省科技计划项目 （ 2012B040301017) 学位申请人 朱小佳 导师姓名 刘雪琴主任护师 专业名称 护理学 培养类型 学术型 培养层次 项士研究生 所在学院 护理学院 答辩委员会主席 李亚洁教授 答辩

2、委员会成员 张立力教授 陈 伟 菊 主 任 护师 张 莉 主 任护师 李漓主任护师 2015 年 05 月 18 日广州 老年护理敏感指标体系的构建及其在 老年糖尿病患者延续护理中的应用 硕士研究生：朱小佳 指导老师：刘雪琴 摘要 研究背景 中国人口老龄化的急速进程与老年慢性病的高发趋势使我国经济社会发展 和医疗卫生服务面临着严峻的挑战。 2014 年中国 60 岁及以上老年人口数量已超 过2.0 亿，老年人慢性病患病率超过 52.4%。老年人通常具有病程长，数病共存 且症状不典型、并发症多且治愈难度大、多重用药引发健康问题、精神心理问 题隐匿、疾病恢复期漫长等特点。针对如此数量庞大且病情复杂

3、的老年人群， 如何确立老年护理工作重点，建立具有较高经济和社会效益的延续护理新模式， 让患者从住院期间延续至出院后的生理、心理和社会等多方面得到全面照护， 不断提高老年患者的结局状态和生存质量，是当今医疗服务体系需要思考的课 题。 目前，许多国家的健康服务系统都逐渐向经济与效率并重的方向重组，在 评价健康服务系统的效益时，越来越重视从健康服务费用与患者结局两方面评 价其有效性。护士是与患者接触最密切的医护人员，在患者疾病康复中发挥重 要作用，但临床护士 疲于应付日常性事务，护理实践的效益无法用有价值的、 规范化的数据呈现，护理学科需要相关数据来支持护理实践的效益和护理对患 者结局的贡献。护理敏

4、感指标是指识别和评估护理在患者结局及健康照护系统 中作用的数据，其在证明护理专业在多学科合作模式中的贡献方面承担着十分 重要的角色。与此同时，护理电子信息化的发展加快了标准化护理语言在建立 摘要 科学化与规范化护理数据库中的应用，为护理敏感指标的建立与完善奠定了坚 实的基础。目前，美国、加拿大、澳大利亚、英国、挪威、丹麦等国家对 本国 护理敏感指标的评估与采集实施由专门机构执行的标准化程序，美国爱荷华大 学护理学院于 20 世纪 90 年代初发起的结局研究项目，建立了全面的以患者结 局为出发点的敏感指标系统，其中压疮、跌倒与坠床、疼痛管理、睡眠情况、 感染的控制、营养状况是老年专科领域研究频率

5、较高的指标。我国护理敏感指 标起步晚，发展不成熟，专科护理敏感指标研究尚处于探索阶段，老年护理敏 感指标多针对老年病医院或老人院质量评价制定，且倾向结构和过程控制，缺 乏以患者结局为导向的老年护理专科领域的护理敏感指标。 糖尿病是当前威胁全球人类健康最重要的慢性病之一，据国际糖尿病联盟 2013年统计，我国糖尿病患者总数已达 9800万，居全球首位，老年人患病率为 20.4%，协助老年糖尿病患者及照顾者正确管理疾病，任重道远。因此本研究选 择老年糖尿病患者为研究应用对象，为今后其他慢性病管理研究提供数据。 研究目的 探讨老年核心护理问题和护理敏感指标，构建老年护理敏感指标体系；构 建以护理敏感

6、指标为依据的老年延续护理干预模式，将其应用于老年糖尿病患 者，为改善老年患者护理结局提供依据。 研究方法 1. 采用 Delphi法，建立以护理 结局为导向的老年护理敏感指标体系。以奥马 哈系统和护理结局分类为理论依据，以临床调研和文献回顾为实证依据，采用 Delphi专家函询法通过便利抽样对 26 名专家就老年核心护理问题和老年护理敏 感指标的确认进行 3 轮函询论证。采用 界值法 筛选老年核心护理问题，敏感度 认可率 90%的指标入选老年护理敏感指标，同时结合专家文字性的意见，课题 组集体评议后完成筛选结果的确认。 2. 以护理敏感指标为依据的老年延续护理干预模式的构建及临床应用。围绕 老

7、年护理敏感指标体系，引用赋能理论、整体护理理论、马斯洛基本需要层次 论等 理论为指导，以奧马哈系统为结构框架，构建以护理敏感指标为依据的老 II 年延续护理干预模式：以老年延续护理实施流程图规范护士行为，用老年延续 护理干预模式记录表实时记录患者从入院到出院后的护理全过程，并引导护士 实施全面的护理评估、诊断敏感的护理问题、制订针对性的护理计划、实施有 效的护理措施、对监测指标进行动态量化的护理评价。在老年糖尿病患者的临 床应用中，采用便利抽样法选取某三级综合医院内分泌科 2014 年 12 月至 2015 年 2 月因糖尿病入院治疗的老年患者 47 例为研究对象。研究前经医院伦理委员 会批准

8、，调查前获得患者的知情同意，通过发放问卷收集数据。在患者入院时 由研究组本人和责任护士每隔 48h进行个体化千预，出院后首个 48h 由研究者 本人进行电话随访，此后每周电话随访一次，出院后 1 个月由研究者本人及糖 尿病专科护士在糖尿病专科门诊随访一次。使用奥马哈系统成效评分表、糖尿 病知识测试问卷、糖尿病患者自我管理行为量表、糖尿病患者生存质量特异性 量表评价患者在入院时、出院前和出院后 1个月的认知、行为、状态改善情况。 3. 研究数据采用 Excel2007和 SPSS 13.0统计软件进行分析。定量资料用 Mean 土 SD 表示，定性资料用构成比（ )表示。专家积极程度用问卷有效回

9、收率和 专家意见提出率表示，专家权威程度用权威系数 （ Cr)表示，专家意见协调程 度用肯德尔协调系数表示。运用百分比权重法对老年核心护理问题进行排序。 用重复测量方差分析检验方法评价患者在入院时、出院前和出院后 1个月在奥 马哈系统成效评分、糖尿病知识得分、自我管理行为得分和生存质量得分改善 情况。 研究结果 1. 函询问卷回收结果显示，来自全国 7 个城市 3 所高等院校 16 所三级综合 综合医院的 26 名专家参与本次函询。 3 轮函询问卷有效回收率分别 86.67%、 100%、96.15%，专家意见提出率分别为 53.85%、 26.92%、 16%，专家权威程度 和 Kendal

10、ls W 协调系数分别为 0.832、 0.864、 0.865 和 0.197、 0.571、 0.583,说 明本次函询研究结果可信。 2. 对老年专科领域核心护理问题的函询结果显示，老年患者在住院期间存在 11 个核心护理问题，涵盖了奥马哈系统问题分类的生理、健康相关行为、心理 III 社会三大领域，分别为：睡眠与休息型态、排便功能、神经 -肌肉 -骨骼功能、药 物治疗方案、循环、身体活动、消化 -水合、个人照顾、疼痛、营养和精神健康。 出院后存在 7 个核心护理问题，涵盖了奥马哈系统问题分类的生理和健康相关 行为两大领域，分别为药物治疗方案、排便功能、睡眠休息型态、神经 -肌肉 - 骨

11、骼功能、身体活动、营养、个人照顾。其中睡眠与休息型态、排便功能、神 经肌肉骨骼功能与药物治疗方案 4 个护理问题为住院期间和出院后两个阶段共 同的核心护理问题（均排在前 4 位 )。 3. 对老年专科领域护理敏感指标函询结果显示，对应老 年专科领域核心护理 问题的护理敏感指标共 54 项。用奥马哈问题分类系统进行归类，核心护理问题 主要分布在生理、健康相关行为和心理社会三大领域。涉及生理领域和健康相 关行为领域的护理敏感指标各 25 个，各占总指标数的 46.30%，涉及心理社会领 域的护理敏感指标共 4 项，占总指标数的 7.40%。专家对生命体征等反映患者病 情变化指标的认可率为 100%

12、，对预防跌倒、药物治疗等维护患者安全的敏感指 标认可率多96%，对电解质平衡、营养状态、睡眠、活动耐力与自理状态等维持 患者内环境稳定和功能健康的敏感指标认可率 92%。 4. 以老年核心护理问题及其护理敏感指标为依据，构建老年延续护理干预模 式并在老年糖尿病患者中进行临床验证。研究结果显示，老年糖尿病患者的核 心护理问题在生理领域主要为神经肌肉骨骼功能、循环、排便功能、疼痛等； 健康相关行为领域主要为营养、药物治疗方案、睡眠与休息型态、身体活动等； 心理社会领域主要为精神健康。实施干预后对以上 9 个核心护理问题的改善状 况及护理效果进行统计学分析，结果显示： 患者核心护理问题结局改善情况：

13、 与入院时比较，出院前及出院后 1 个月患者核心护理问题的认知、行为、状态 的改善有统计学意义 （ P0.05)，其他护理问题的认知、行为、状态改善均有统计学意义 （ P0.05)， 其他维度得分提高均有统计学意义 （ P1 个月），是护理人员延续护理随访关 注的重点。 3. 本研究证实标准化护理语言奥马哈系统与护理结局分类易于被临床护理 人员理解和接受，能成功链接并联合应用于我国老年延续护理干预模式中。 关 键 词 护 理 敏 感 指 标 老 年 护 理 护 理 结 局 糖 尿 病 V Design and Application of Geriatric Nursing Sensitive

14、 Indicator System in Transitional Care of Elderly Patients with Diabetes Mellitus Name: Zhu Xiaojia Supervisor: Liu Xueqin ABSTRACT BACKGROUND China9s social-economic development and the health care system are facing great challenges owing to the rapidly aging populations and high incidence of chron

15、ic diseases in the elderly. More than 200 million elderly people lived in china in 2014, among whom the morbidity of chronic diseases was over 52.4%. There are some special characteristics for elderly patients, such as long duration of diseases, coexisting with many health problems, atypical symptom

16、s, and difficult cure for many complications, unsuccessful drugs administration, concealed psychological problems, and long convalescence of diseases. Considering the large number and complicated conditions in elderly patients, how to identify the geriatric nursing priorities as well as establish a

17、new transitional care model with high economic and social benefits to take folly care of them in physiological, psychological and social aspects as well as from admission to discharge, and constantly improve their outcomes and quality of life, axe what the health care system should be taken into con

18、sideration. At present, the heath care system in many countries has been paying equal attention to economic and efficiency. When it comes to the evaluation of its effectiveness, the government and the people put more emphases on health service expenses and patient outcomes. Nurses play significant r

19、ole in patients5 rehabilitation. However, nurses are usually busy with daily affairs whose professional values are not evident. Nursing behaviors and their influences for patient outcomes are often overlooked. In order to avoid such situation, nursing effectiveness and its contributions for patient

20、outcomes call for supportive data. As the identifying and evaluating data for patients and health care system, the nursing sensitive indicators play a significant role in the contributions for multidisciplinary collaborations. Furthermore, the development of nursing informationization accelerates th

21、e application of standardized nursing terminologies in nursing database scientifically and normatively, which lays a solid foundation for the design and promotion of the nursing sensitive indicators. In recent years, six nations (USA, Canada, Australia, England, Norway, Denmark) have nationally stan

22、dardized assessment and collection of nursing sensitive indicators. The university of Iowa college of Nursing developed a comprehensive classification of nursing-sensitive patient outcomes in 1990s, among which ranked highest in geriatric nursing were pressure ulcers, falls ?pain management, sleep c

23、onditions, infection control and nutrition conditions. Nursing sensitive indicators in china started late and immaturely, the majority of which are nursing quality management indicators, the specialized researches of which are still on the early stage. Geriatric nursing sensitive indicators are main

24、ly refer to quality evaluation for skilled nursing facilities or geriatric hospitals, most of which focused on structure and process study. There is a phenomenon that china is lack of the nursing sensitive indicators based on patient outcomes in geriatric nursing. Diabetes is currently one of the mo

25、st important chronic threats to human health worldwide. According to the International Diabetes Federation (IDF) 2013 statistics, there are 98.4 million diabetes in China, the morbidity of which in elderly was 20.4%. It would go a long way toward helping patients and their families proper management

26、 of diabetes. Therefore, this study chose elderly diabetic patients as our target subject, to provide nursing data for the future research of other chronic disease. OBJECTIVES To explore core nursing problems and nursing sensitive indicators in geriatric nursing. To design a geriatric nursing sensit

27、ive indicator system. To establish a transitional care model based on geriatric nursing sensitive indicator system. To explore the application of the model in elderly patients with diabetes and provide evidence for promoting the nursing outcomes. METHODS 1. Using Delphi technique to design a geriatr

28、ic nursing sensitive indicator system oriented by Nursing Outcomes Classification. To identify the core nursing problems and nursing sensitive indicators for geriatric nursing, a Delphi technique was used to recognize three rounds of 26 experts9 consultations with Omaha System and Nursing Outcomes C

29、lassification as the theoretical basis as well as clinical researches and reference literatures as the empirical basis. Geriatric core nursing problems were screened by the critical value method. Indicators whose sensitivity above 90% were selected to geriatric nursing sensitive ones. Combined with

30、experts consultations， the research results were confirmed after the research groups discussion. 2. Design and application of the transitional care model based on nursing sensitive indicators in elderly patients. Centering on the geriatric nursingsensitive indicator system and guided by some theorie

31、s such as Empowerment, Holistic nursing care and Maslow9s hierarchy of needs theory, the geriatric transitional care model was designed framed with the Omaha System. A performing flow chart for the model was designed to standardize nursing actions. A record form for the model contained a comprehensi

32、ve nursing procedure form hospitalization to discharge. With which patients would be served with comprehensive nursing assessment, sensitive nursing diagnosis， targeted nursing plan， effective nursing intervention， and dynamic nursing evaluation. Then the model was applied to the elderly patients wi

33、th diabetes. A convenience sample was recruited from a Level Three general hospital at inpatient department of endocrinology in Guangzhou from December 2014 to February 2015. A total of forty-seven patients were recruited. Human subject ethic review was approved by the institutional review board of

34、the hospitals and informed consent to iii participate was obtained before data collection. The study was implemented by gathering survey data. During hospitalization, nurses performed individualized interventions per 48h. After discharge, a telephone follow-up was made within 48h and once a week sub

35、sequently. At last, patients were asked to have a return visit to Diabetes Specialty Clinics within 1 month after discharge. We evaluated the improvement of knowledge, behavior and status by using Omaha System Problem Rating Scale for Outcomes, Diabetes Knowledge Test (DKT), Summary of Diabetes Self

36、-Care Activities Measure (SDSCA) and Diabetes Specific Quality of Life Scale (DSQL) at the time of admission, the day before discharge and 1 month after discharge. 3. Analyses were performed using Excel2007 and SPSS 13.0. Qumititative variables were described using mean 土 SD， and percentage for cate

37、gorical variables. The experts5 positive coefficient was represented by the effective return rate and propose suggestion rate. Cr stood for the experts authority level and Kendalls W stood for the experts5 coordination Level. Core nursing problems was ranked with percentage weight method. The improv

38、ements of scores in nursing outcomes, diabetes knowledge, self-care behaviors and quality of life were analyzed with repeated measures ANOVA at the time of admission, the day before discharge and 1 month after discharge. RESULTS 1. Three rounds of Delphi study were conducted in 7 cities, 3 universit

39、ies and 16 3-A-grade hospitals by 26 experts nationally. The effective return rate for 3rounds consultation were 86.67%, 100%, 96.15%, the propose suggestion rate for which were 53.85%， 26.92%, 16%， Cr and Kendalls W of which were separately 0.832, 0. 864, 0.865 and 0.197, 0.571, 0,583. It turned ou

40、t that the results of this study were reliable. 2. There were 11 core nursing problems of the elderly during hospitalization, involved into physical domain, health-related domain and social-psychological domain. They were sleep and rest patterns, bowel function, neuro-musculo-skeletal function, medi

41、cation regimen, circulation, physical activity, digestion-hydration, iv personal care, pain, nutrition and spirituality. At the same time, after discharge there were 7 core nursing problems which were medication regimen, bowel function, sleep and rest patterns, neuro-musculo-skeletal function, physi

42、cal activity, nutrition and personal care. Among them, sleep and rest patterns, bowel function, neuro-musculo-skeletal flmction and medication regimen were common core nursing problems which ranked 4rd during two phases. .3. Classified by Omaha System, 54 geriatric nursing sensitive indicators which

43、 were linked to the core nursing problems were involved into physical domain, health-related domain and social-psychological domain. There were 25 sensitive indicators in both physical domain and health-related domain, accounting for 463% of the total separately. The percentage of 4 sensitive indica

44、tors in social psychological domain was 7.4%.The approval rate of Vital signs, as one of the sensitive indicators to reflect patients5 condition, was 100%. The approval rate of indicators referring safe such as fall prevention and drugs administration were over 96%. When it comes to keep homeostasis

45、 balanced and maintain function healthy such as electrolyte, nutrition, sleep, activity and self-care, the approval rate of indicators were above 92%. 4. The 9 core nursing problems in elderly patients with diabetes were as follows: physical domain included neuro-musculo-skeletal fiinction, circulat

46、ion, bowel function and pain; health-related domain included nutrition, medication regimen, sleep and rest patterns and physical activity; social-psychological domain was spirituality. After nursing interventions， the results were as follows: Compared with admission, patients showed significant diff

47、erences in the Knowledge, Behavior, and Status of the 9 core nursing problems at the day before discharge and 1 month after discharge (0.05) Patients showed significant differences in the promotion of the DKT in three stages (P0.05) .Compared with admission, patients showed significant differences i

48、n total and each factor score of the DSQL at the day before discharge and 1 month after discharge (P。随着健康服务系统逐渐向增加经济效益的方向重组 , 患者结局指标越来越受到重视，美国爱荷华大学护理学院于 20 世纪 90 年代初 发起结局研究项目，建立了全面的以患者结局为出发点的敏感指标系统，在急 诊科、手术室、 ICU、 产科、老年等不同专科领域得到了广泛应用，其中压疮、 跌倒与坠床、疼痛管理、睡眠情况、感染的控制、营养状况是老年专科领域研 究频率较高的指标 21， 22。我国护理敏感指标起

49、步晚，发展不成熟，以评价 护理 质量的技术管理指标为主，如基础护理合格率、急救物品管理合格率，技术操 作合格率、消毒隔离管理合格率等 M。 专科护理敏感指标研究尚处于探索阶段， 老年护理敏感指标多针对老年病医院或老人院质量评价制定 24, 25，且倾向结构 和过程控制 26，缺乏以患者结局为重点的老年护理专科领域的护理敏感指标。 1.5 护理电子信息化与标准化护理语言的密切关系 随科技的迅速发展，无论在发达国家还是发展中国家，医疗服务系统越来 越倾向用电子信息记录来对临床的数据进行存储与分析，电子健康记录与信息 学研究已 成 为 医 疗 服 务 系 统 不 可 抗 拒 的 发 展 趋 势 。 护 理 信 息 化 （ Nursing Informationization)具有提高护理绩效、拓宽护理知识、为护理学科参与医疗卫 生政策的制定提供必需的数据