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《Chinese Journal of Nursing》 2011-08
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Transitional care for a patient with chronic obstructive pulmonary disease

WANG Shao-ling,FU Shi-yan,CHOW Ka-yee,WONG Kam-yuet  
A case study was conducted to demonstrate the implementation and outcomes of a transitional care program for Chinese patients with COPD.The program had two phases:discharge planning,and post-discharge home visit and telephone follow up.Nursing intervention included comprehensive assessment,mutual goal setting,individualized health education,guidance and counseling,treatment and procedure,case management and surveillance,and continuous evaluation.The key to success is to implement standardized evidence-based intervention protocols in clinical care.
【CateGory Index】: R473.5
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