徐蓉 沈雁红 徐丽娜 梁松梅 袁心慧 陆晓燕

摘 要 目的：探讨对脑卒中患者实施从住院到社区无缝隙护理管理模式的效果。方法：选取2018年7月至2019年6月在上海市杨浦区殷行社区卫生服务中心住院治疗的脑卒中患者60例，随机分为观察组和对照组各30例。观察组采用从病房到社区无缝隙护理管理模式，对照组接受常规护理。在出院时、出院后6个月分别应用Barthel指数评定量表（BI）和Fugl-meyer运动功能评定量表（FM）评估患者的日常生活能力、运动功能，并对平衡饮食、正常作息、康复训练、正规服药和复诊随访等遵医行为进行评价。结果：出院6个月后，观察组BI指数、FM指数和遵医行为均较对照组明显提高，差异有统计学意义（P均<0.05）。结论：应用从病房到社区无缝隙护理管理模式能够对脑卒中患者进行有效的管理，提高其日常生活能力、运动功能及遵医行为，改善预后。

关键词 脑卒中；社区护理；无缝隙护理；日常生活能力

中图分类号：R743.3 文献标志码：A 文章编号：1006-1533（2020）10-0039-04

Analysis of the application effect of seamless nursing management mode from hospitalization to community in stroke patients

XU Rong1， SHEN Yanhong1， XU Lina2， LIANG Songmei2， YUAN Xinhui2， LU Xiaoyan2

（1. Medical Department of Yinhang Community Health Service Center of Yangpu District， Shanghai 200438， China； 2. Nursing Department of Yinhang Community Health Service Center of Yangpu District， Shanghai 200438， China）

ABSTRACT Objective： To explore the effect of implementing seamless nursing management mode for stroke patients from hospitalization to community. Methods： Sixty stroke patients who were hospitalized at Yinhang Community Health Service Center in Yangpu District， Shanghai for treatment from July 2018 to June 2019 were selected， and randomly divided into an observation group and a control group with 30 cases in each group. The observation group adopted seamless nursing management mode from ward to community， and the control group received routine nursing. At the time of discharge and 6 months after discharge， the Barthel index rating scale（BI） and the Fugl-meyer motor function rating scale（FM） were used to assess patientsdaily living ability and motor function， and the balance diet， normal rest， recovery training， regular medication and follow-up revisits were evaluated. Results： After discharge of six months， the BI index， FM index and compliance behavior of the observation group were significantly higher than those of the control group， and the differences were statistically significant（all P<0.05）. Conclusion： Applying seamless care management mode from ward to community can effectively manage the stroke patients， and improve their daily life ability， motor function and compliance behavior， which can improve the prognosis.

KEY WORDS stroke； community nursing； seamless nursing； daily living ability

流行病學研究显示，脑血管病已跃居我国疾病死因的首位[1-2]。我国每年新发脑卒中患者约200万人，其中 70%～80%的脑卒中患者因为残疾不能独立生活。脑卒中的高发病率、高死亡率、高致残率和易复发性给患者、家庭以及社会带来沉重的负担[1]。随着医疗水平的不断提高，其死亡率下降，但致残率仍不断增加，严重影响患者生存质量。循证医学证实，出院后积极有效的脑卒中康复治疗能有效降低致残率，也是脑卒中管理的关键环节。但由于医疗资源不足，患者出院后的医疗、护理和康复关注不到位。有些脑卒中患者回到家中不能主动进行康复锻炼，导致复发，严重影响其预后。……