老年慢性病患者居家护理需求与护理干预效果的横断面研究

A Cross-Sectional Study on Home Care Needs and the Effectiveness of Nursing Interventions for Elderly Patients with Chronic Diseases

摘要: 目的：探讨老年慢性病患者的居家护理需求现状，分析个性化护理干预对患者生活质量、疾病管理能力及再住院率的影响，为优化老年居家护理服务模式提供依据。方法：采用横断面调查与干预研究相结合的方法，选取2023年1月~2023年12月在某社区卫生服务中心建档的老年慢性病患者320例，其中高血压142例、糖尿病98例、慢性阻塞性肺疾病(COPD) 51例、冠心病29例。通过自制问卷评估患者居家护理需求，按随机数字表法分为干预组(160例)和对照组(160例)。对照组接受常规社区护理指导，干预组在常规护理基础上实施6个月个性化居家护理干预，包括健康监测、用药指导、康复训练、心理疏导及家庭照护者培训。比较两组干预前后生活质量量表(SF-36)评分、疾病管理能力评分及1年内再住院率。结果：老年慢性病患者居家护理需求前三位为：用药指导(89.38%)、定期健康监测(85.63%)、康复训练指导(81.25%)。干预6个月后，干预组SF-36量表各维度评分(生理功能68.42 ± 8.35、生理职能62.15 ± 9.21、躯体疼痛59.36 ± 10.12、一般健康状况65.78 ± 8.96、精力63.24 ± 9.03、社会功能67.51 ± 8.47、情感职能64.38 ± 9.15、精神健康66.82 ± 8.73)均显著高于对照组(P < 0.05)；干预组疾病管理能力评分(82.65 ± 7.42)显著高于对照组(65.38 ± 8.16) (P < 0.05)；干预组1年内再住院率(12.50%)显著低于对照组(26.25%) (χ² = 10.286, P = 0.001)。结论：老年慢性病患者居家护理需求多元化，以用药指导、健康监测和康复训练为核心需求。个性化居家护理干预可有效提升患者生活质量和疾病管理能力，降低再住院率，值得在社区老年护理中推广应用。

Abstract: Objective: This paper aims to explore the current status of home care needs among elderly patients with chronic diseases, analyze the impact of personalized nursing interventions on patients’ quality of life, disease management ability, and hospital readmission rate, and provide a basis for optimizing home care service models for the elderly. Methods: A combination of cross-sectional survey and intervention study was adopted. A total of 320 elderly patients with chronic diseases registered in a community health service center from January 2023 to December 2023 were selected, including 142 cases of hypertension, 98 cases of diabetes mellitus, 51 cases of chronic obstructive pulmonary disease (COPD), and 29 cases of coronary heart disease. The patients’ home care needs were assessed using a self-developed questionnaire. They were divided into an intervention group (160 cases) and a control group (160 cases) using a random number table method. The control group received routine community nursing guidance, while the intervention group received personalized home care interventions for six months based on routine nursing, including health monitoring, medication guidance, rehabilitation training, psychological counseling, and training for family caregivers. The two groups were compared in terms of the scores of the Short-Form 36 Health Survey (SF-36), disease management ability scores, and hospital readmission rate within one year before and after the intervention. Results: The top three home care needs among elderly patients with chronic diseases were medication guidance (89.38%), regular health monitoring (85.63%), and rehabilitation training guidance (81.25%). After six months of intervention, the scores of all dimensions of the SF-36 scale in the intervention group (physiological function 68.42 ± 8.35, role-physical 62.15 ± 9.21, bodily pain 59.36 ± 10.12, general health 65.78 ± 8.96, vitality 63.24 ± 9.03, social function 67.51 ± 8.47, role-emotional 64.38 ± 9.15, mental health 66.82 ± 8.73) were significantly higher than those in the control group (P < 0.05). The disease management ability score of the intervention group (82.65 ± 7.42) was significantly higher than that of the control group (65.38 ± 8.16) (P < 0.05). The hospital readmission rate within one year in the intervention group (12.50%) was significantly lower than that in the control group (26.25%) (χ² = 10.286, P = 0.001). Conclusion: Elderly patients with chronic diseases have diverse home care needs, with medication guidance, health monitoring, and rehabilitation training being the core needs. Personalized home care interventions can effectively improve patients’ quality of life and disease management ability and reduce the hospital readmission rate, making them worthy of promotion and application in community elderly care.