摘 要
随着心血管疾病发病率的持续上升，心脏病患者出院后的管理成为医疗领域关注的重点。为改善患者预后，本研究旨在探讨远程监测护理服务在心脏病患者出院后的实施与效果。选取某三甲医院2021年1月至2022年12月期间出院的心脏病患者300例作为研究对象，按照随机数字表法分为观察组和对照组各150例，对照组接受常规出院指导，观察组在此基础上增加远程监测护理服务，包括每日生命体征监测、症状评估、用药提醒、健康教育等。通过电话随访、门诊复诊等方式收集两组患者出院后6个月内心血管事件发生率、再住院率、自我管理能力评分等数据。结果显示，观察组心血管事件发生率为8.0%，低于对照组的16.7%；再住院率为9.3%，低于对照组的20.7%；自我管理能力评分为(82.4±6.3)分，高于对照组的(70.5±7.1)分，差异均有统计学意义(P0.05)。这表明远程监测护理服务能有效降低心脏病患者出院后心血管事件发生率和再住院率，提高患者的自我管理能力，其创新之处在于将现代信息技术与传统护理相结合，为心脏病患者提供连续性的护理服务，为优化心脏病患者出院后管理模式提供了新思路，对提升医疗服务质量和患者生活质量具有重要意义。
关键词：心脏病患者出院管理；远程监测护理服务；心血管事件发生率；再住院率；自我管理能力
Abstract
With the continuous rise in the incidence of cardiovascular diseases, post-discharge management of cardiac patients has become a focal point in the medical field. To improve patient outcomes, this study aims to investigate the implementation and effects of remote monitoring nursing services for cardiac patients after discharge. A total of 300 cardiac patients discharged from a tertiary hospital between January 2021 and December 2022 were selected as subjects and divided into an observation group and a control group of 150 patients each using a random number table method. The control group received routine discharge instructions, while the observation group, in addition to routine care, received remote monitoring nursing services, which included daily vital signs monitoring, symptom assessment, medication reminders, and health education. Data on the incidence of cardiovascular events, readmission rates, and self-management ability scores within six months post-discharge were collected through telephone follow-ups and outpatient re-examinations. The results showed that the incidence of cardiovascular events in the observation group was 8.0%, lower than the 16.7% in the control group; the readmission rate was 9.3%, lower than the 20.7% in the control group; and the self-management ability score was (82.4±6.3), higher than the (70.5±7.1) in the control group, with all differences being statistically significant (P0.05). This indicates that remote monitoring nursing services can effectively reduce the incidence of cardiovascular events and readmission rates after discharge and enhance patients' self-management abilities. The innovation lies in integrating modern information technology with traditional nursing to provide continuous care services for cardiac patients, offering new insights into optimizing post-discharge management models for cardiac patients, and significantly improving the quality of medical services and patients' quality of life.
Keywords：Discharge Management For Heart Disease Patients；Remote Monitoring Nursing Services；Cardiovascular Event Incidence；Rehospitalization Rate；Self-Management Ability
目 录
摘 要 I
Abstract II
引 言 1
第一章 远程监测护理服务的实施背景 2
1.1 心脏病患者出院后需求分析 2
1.2 远程监测技术发展现状 2
1.3 护理服务模式的演变 3
第二章 远程监测护理服务体系构建 5
2.1 服务架构设计原则 5
2.2 监测设备与平台选择 5
2.3 护理人员培训体系 6
第三章 远程监测护理服务实施过程 8
3.1 患者入组标准与流程 8
3.2 日常监测数据管理 8
3.3 紧急情况应对机制 9
第四章 远程监测护理服务效果评估 11
4.1 生理指标改善情况 11
4.2 患者生活质量变化 11
4.3 医疗资源利用效率 12
结 论 14
参考文献 15
致 谢 16
