Abstract: Objective: To explore the effectiveness of the Theory of Phased Behavior Transformation in continuing care for patients with chronic kidney disease (CKD). Methods: A total of 160 outpatients with CKD were selected as study subjects and randomly divided into control group (n=80) and observation group (n=80). The control group received outpatient support combined with education through online official account, while the observation group received interventions based on the Theory of Phased Behavior Transformation. Both interventions lasted for 6 months. Changes in self-management ability, self-efficacy, and laboratory indicators were analyzed for both groups before the intervention, after 6 months of intervention, and at the 6-month follow-up. Results: After 6 months of intervention and at the 6-month follow-up, significant differences were observed between the two groups in self-management ability, self-efficacy, systolic blood pressure, serum creatinine, serum potassium, serum phosphorus, hemoglobin, and albumin (P<0.05). At the 6-month follow-up, significant differences were also found between the two groups in diastolic blood pressure and serum uric acid levels (P<0.05). Conclusion: The implementation of continuing care based on the Theory of Phased Behavior Transformation can effectively improve self-management ability and self-efficacy in CKD patients, thereby delaying the progression of the disease.

Key words: Theory of Phased Behavior Transformation, Continuing care, Chronic kidney disease, Self-management, Self efficacy

摘要： 目的：探讨行为分阶段转变理论在慢性肾脏病患者延续护理中的应用效果。方法：选取慢性肾脏病门诊患者160例为研究对象，随机分为对照组及观察组各80例，对照组给予门诊支持联合公众号教育，观察组给予以行为分阶段转变理论为基础的干预，均干预6个月。分析两组患者干预前、干预6个月及12个月的自我管理能力、自我效能及实验室指标的变化趋势。结果：干预6个月及12个月，两组患者自我管理能力、自我效能、收缩压、血肌酐、血钾、血磷、血红蛋白、血白蛋白差异有统计学意义（P<0.05）。干预后6个月，两组患者舒张压及血尿酸差异有统计学意义（P<0.05）。结论：以行为分阶段转变理论为基础实施延续护理可有效改善慢性肾脏病患者的自我管理能力及自我效能，延缓疾病进展。

关键词: 行为分阶段转变理论, 延续护理, 慢性肾脏病, 自我管理, 自我效能