Revista de Enfermagem e Cuidados

Specialised Nursing-based Transitional Care in Elderly Patients with Chronic Diseases

Abstract

Xia Lyu*, Jinling Li, Wuhong Deng, Hongying Hu, Jie Zeng and Jenny Song

The purpose of this study is to explore the influence of transitional care by specialty nurses (SN) for elderly patients with dementia.
A total of 104 patients with dementia suffering from various diseases of the elderly were invited to participate in this research project in the Department of Internal Medicine in Shenzhen People's hospital from September 2015 to February 2016. Using purposive sampling, the patients were assigned into two groups: the control group and the observation group. Patients in both groups were evaluated before discharge. Patients in the control group were given only routine nursing care and telephone follow-up in the first month after discharge. Patients in the observation group were given transitional care on the top of the usual care offered. The unscheduled readmission rate, compliance behavior and incidence of complications for those discharged with tubes after discharge were compared between the groups.
The results showed that the unscheduled readmission rate of patients in the observation group decreased, compliance behavior improved and the incidence of complications for those discharged with indwelling catheters (IDC) was reduced. There were statistically significant differences in data between the groups.
Transitional care led by specialized nurses can lower the readmission rate, reduce complications, and improve compliance behavior, which results in a quick recovery for patients after discharge.