慢性肾脏病患者基于多种网络平台的全链式管理
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女,硕士,护士

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科研项目:武汉市护理学会资助项目(WHHL202409)


Comprehensive continuum-of-care management for chronic kidney disease patients utilizing multiple digital platforms
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    目的 探讨基于多种网络平台的全链式管理对慢性肾脏病患者肾功能、服药依从性及自我管理能力的影响,为优化慢性肾脏病患者的全程管理提供参考。 方法 将72例慢性肾脏病患者随机分为对照组和观察组各36例。对照组采用常规护理,观察组在常规护理基础上通过微信群及公众号、抖音、肾尚App实施从门诊到出院后的全链式管理,干预时间为6个月。比较两组患者干预前后肾功能(尿素氮、血清肌酐、肾小球滤过率)、服药依从性及自我管理能力。 结果 干预后观察组尿素氮、血清肌酐显著低于对照组,肾小球滤过率显著高于对照组(均P<0.05)。观察组服药依从性和自我管理能力评分显著高于对照组(均P<0.05)。 结论 基于多种网络平台的全链式管理能够改善慢性肾脏病患者的肾功能,提升其服药依从性和自我管理能力,以延缓疾病进程。

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    Objective To evaluate the impact of a comprehensive continuum-of-care management model, delivered via multiple digital platforms, on renal function, medication adherence, and self-management ability in patients with chronic kidney disease (CKD), and to provide a reference for optimizing the management of this patient population throughout their care journey. Methods A total of 72 patients with CKD were randomly assigned to either a control group (n=36) or an intervention group (n=36).The control group received standard nursing care, while the intervention group additionally received a 6-month, platform-based comprehensive continuum-of-care management program spanning from outpatient clinic to post-discharge.This program utilized WeChat groups, official WeChat accounts, Douyin (TikTok), and the dedicated "KidneyCare" mobile application.Renal function parameters (blood urea nitrogen, serum creatinine, estimated glomerular filtration rate), medication adherence, and self-management ability were compared between the two groups before and after the intervention. Results After the intervention, the intervention group showed significantly lower levels of blood urea nitrogen and serum creatinine, and a significantly higher estimated glomerular filtration rate compared to the control group (all P<0.05).Scores for medication adherence and self-management ability were also significantly higher in the intervention group (all P<0.05). Conclusion Comprehensive continuum-of-care management utilizing multiple digital platforms can improve renal function, medication adherence, and self-management ability in patients with CKD, contributing to slowing disease progression.

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张瑾,汪晓攀,谭瑶,李知凌,杨大航.慢性肾脏病患者基于多种网络平台的全链式管理[J].护理学杂志,2026,41(5):110-114

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  • 收稿日期:2025-10-26
  • 最后修改日期:2025-12-28
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  • 在线发布日期: 2026-03-31