目的 构建冠心病患者经皮冠状动脉介入治疗（percutaneous coronary intervention,PCI）术后延续护理方案。方法 运用文献回顾法,基于King达标理论初步形成方案内容,采用专家论证法论证方案的科学性和可行性,构建基于共同目标的冠心病PCI术后延续护理方案。结果 方案包括基于共同目标的面对面指导、每2周1次的电话随访2部分内容,共持续12周。基于共同目标的面对面指导包括借助自我管理手册、自我管理工具的健康指导及共同目标合约签订,于PCI术后第1天进行,约30~60 min。电话随访从患者纳入后第2周开始,每2周1次,共6次,每次随访时间5~10 min。护患双方感知、判断患者近2周共同目标的执行情况并采取行动,必要时动态调整共同目标。结论 达标理论指导下的基于共同目标的冠心病PCI术后延续护理方案科学性较好,有助于指导延续护理实践。

Objective To develop a mutual-goal based continuous nursing program for patient with coronary heart disease（CHD） after percutaneous coronary intervention（PCI）. Methods Contents of the program were formed preliminarily by the literature review based on the King theory of goal attainment. Expert argumentation was used to demonstrate the scientific nature and feasibility of the program,to develop the mutual-goal based continuous nursing program for CHD after PCI. Results This program included two parts：face-to-face education based on mutual goals,and every 2-week telephone follow-ups,in a total of 12 weeks. Face-to-face education based on mutual goals included health education with the help of a self-management manual,self-management tools and mutual goal contracts. The education was performed on the first day after PCI,lasting about 30~60 mins. The telephone follow-up started from the second week after inclusion,and was conducted once every two weeks for a total of 6 weeks. Each follow-up lasted for 5~10 mins. Both nurse and patients perceived and judged the patients’ implementation of the mutual goals in the past two weeks and took actions,and dynamically adjusted the mutual goals when necessary. Conclusion This developed mutual-goal based continuous nursing program under the guidance of King theory of goal attainment for patients with CHD after PCI has been preliminarily proved feasible and scientific.