RESUMO
Objective Peritoneal dialysis can be done at home , however , its clinical follow-up quality is lower compared with hemodialysis due to the lack of detailed follow-up system and professional management team for post-discharge nursing care .The article aimed to explore the effect of a nurse-led integrated specialized disease management model in the follow-up of peritoneal dialysis patients . Methods Nurse-led integrated specialized disease management model was provided for 270 patients with peritoneal dialysis (PD) from January 2012 to May 2013.Self-designed questionnaire on diasease knowledge and self-care assement questionnaire were used for patients to evaluate their self-care ability and understanding of disease knowledge .Regular follow-up continued . Results The patients′understanding of disease knowledge was on the rise at 1st day before discharge, 1st month and 3rd months after discharge. After the application of nurse-led integrated specialized disease management model , the patients′regular clinical follow-up rate was in-creased from 78.3% to 88.6%.The patients′self-care ability improved gradually at 1st day before discharge , 1st month and 3rd months after discharge , which was of significant differences . Conclusion The nurse-led nurse-led integrated specialized disease management model can improve peritoneal dialysis patients′self-care ability and reduce their medical expense , which is of clinical sig-nificance .