- 期刊
降低血液透析治療之體重異常發生件數
Reduce the Number of Abnormal Weight Abnormalities in Hemodialysis Treatment
摘要
本專案統計2020年季平均發生體重異常件數為1件，2021年第一季驟升至4件且有2件造成肺水腫、休克且遭家屬投書，怒罵護理師打擊信心，故引發改善動機。分析其主要問題包含：護理師對血液透析正確測量體重認知不足、護理師未落實執行雙人覆核透析機設定、病人及主要照顧者對血液透析正確測量體重認知不足、缺乏正確測量體重之在職教育及衛教工具。安排教育訓練、訂定規範、製作多元化及多國語言衛教工具、LINE@護腎服務平台訊息等措施；專案結果血液透析治療之體重異常件數由原先4自件降為0件，專案推行至2021年第四季維持無異常發生，專案改善後大幅減少護理師工作負荷及提升病人透析照護品質及安全。
並列摘要
According to the statistics of this project, the average number of cases with abnormal body weight in the first quarter of 2020 was one. However, this number increased to four in the first quarter of 2021. Moreover, two of these cases resulted in pulmonary edema and shock, leading to complaints from their families. The nurses, who were scolded and discouraged by angry family members, lost confidence, which served as a motivation for improvement. The main problems identified during the analysis are as follows: nurses' lack of recognition of correct weight measurement during hemodialysis, nurses' failure to implement two-person review of dialysis machine settings, patients' and primary caregivers' lack of awareness regarding correct weight measurement during hemodialysis, and insufficient availability of in-service education and health education tools for proper weight measurement. To address these issues, the following measures were implemented: arrangements for education and training, formulation of standards, production of diverse and multi-language health education tools, and utilization of the LINE@kidney care service platform. As a result, the number of weight abnormalities during hemodialysis treatment decreased from four to zero, and no abnormalities were observed until the fourth quarter of 2021. The implementation of these improvements significantly reduced the workload of nurses and enhanced the quality and safety of dialysis care for patients.