基于社会支持理论的老年辅助腹膜透析患者疾病管理模式的构建和效果评价

Assisted peritoneal dialysis is suitable, but not limited to, elderly patients who are unable to perform peritoneal dialysis by themselves. Inadequate training and education for patients and assistants may result in unfavorable outcomes. This program aims to develop a social support theory-based disease management program for this group of patients, as so to improve patients’ outcomes. Cross-sectional investigation will be adopted to explore the clinical characteristics of assisted peritoneal dialysis patients. The primary-secondary provider model is used to guide the design of the intervention. The nurses will serve as secondary provider assists primary provider-the family member in meeting the needs of the patients. A nurse-led, family supported intervention will be developed based on research evidence and the results of the cross-sectional investigation. The project will then adopt a quasi-experimental design to evaluate the efficacy of the disease management program. The process evaluation will be embedded in the study to explore the underlying change principles of the intervention. Semi-structured interviews with nurses and group discussions with patients, family members who participated in the program, and documentary analysis will be used to explore the implementation of the program, the context of implementation and change mechanisms which influence and shape the patients’ outcomes. The results of the project will generate valuable evidence to further confirm the effects of family member training in improving patients’ health-related quality of life and clinical outcomes. Nurses providing intervention will received structured training on the disease management for assisted peritoneal dialysis; which will be served as a piece of evidence for establishing the specialist nursing practice in peritoneal dialysis in mainland China.

辅助腹膜透析用于无法独立完成腹透换液操作的老年患者。本项目将通过现状调研，分析老年辅助腹膜透析患者临床特点和管理现状；进而以社会支持理论为指导，结合文献综述和前期调研结果，构建以腹透护士为主导的，家属参与的老年辅助腹膜透析患者疾病管理模式；并通过自身前后对照研究嵌入过程评估的研究设计评价该模式的成效，从而阐明腹透护士对家属培训在改善老年辅助腹膜透析患者的生活质量和治疗结局的作用，并建立腹透护士在老年辅助腹膜透析患者疾病管理中的角色和工作模式，为推动腹透专科护士的发展提供一定的参考依据。

随着人口老龄化，接受腹膜透析治疗的老年终末期肾脏病患者比例将快速增长。由于视力下降等原因，相当比例的老年患者需在家人或其他人员帮助下进行透析换液，即辅助腹膜透析。目前腹膜透析疾病管理内容尚不足以应对老年（辅助）腹膜透析患者生理、心理和社会功能现状，且在模式构建上缺乏理论框架。.本项目通过横断面调查研究，确定了老年腹膜透析患者生活质量现状及其影响因素；并明确影响其照顾负荷的患者因素。基于观察性研究结果，以社会支持理论为框架，构建了以营养和运动为干预靶点、护士主导、家属参与的老年（辅助）腹膜透析患者疾病管理方案。通过类实验研究设计，检验该模式的应用效果。.本项目观察性研究结果显示：老年腹膜透析患者生活质量较低，患者躯体功能，营养状态以及抑郁症状水平是其生活质量的主要影响因素；且患者工具性日常生活活动能力障碍、抑郁症状水平亦是影响其家庭照顾者照顾负担的主要因素。类实验研究结果显示：接受方案干预3个月后，老年（辅助）腹膜透析患者的膳食蛋白质摄入量、每日步行时间、每周体力活动的能量消耗、计时起立行走测试表现均显著高于干预前；且患者老年抑郁量表得分明显低于干预前。生活质量各维度得分均呈现升高趋势，但仅社会功能维度得分差异具有统计学意义。.本项目实验性研究结果提示，以营养和运动为干预靶点、护士主导、家属参与的疾病管理模式，能够有效提高老年（辅助）腹膜透析患者的膳食蛋白摄入量，提高体力活动水平；改善躯体功能表现，降低抑郁水平；但是在改善生活质量方面效果尚不明显，这可能与样本量小且观察时间较短有关，还需要进一步观察和验证。.本项目从临床腹膜透析随访管理实际出发，充分考虑老年患者的身心特点，构建了以营养和运动为干预靶点的老年（辅助）腹膜透析患者疾病管理模式，一定程度上满足了患者的护理需求，亦有助于规范以护士为主导的老年腹膜透析患者随访管理服务，为进一步完善腹膜透析专职护士的服务内容和规范提供一定的参考。