一位糖尿病末期腎衰竭患者面臨血液透析與併發心肌梗塞之不確定感照護經驗

Care Experience of a Diabetic End-Stage Renal Failure Patient after Undergoing Hemodialysis

劉曉慧(Hsiao-Hui Liu):宋振美(Chen-Mei Sung) ； 伍碧霞(Pi-Hsia Wu)

《榮總護理》 35卷1期 (2018/03) Pp. 70-78

https://doi.org/10.6142/VGHN.201803_35(1).0008

摘要

本文乃探討一位糖尿病末期腎衰竭患者在面臨血液透析治療時，因無望、憂鬱而產生有害程度之確定感，以及在血液透析治療期間併發心肌梗塞而產生高度不確定感，導致個案對於治療時瘻管流速不佳是否至外科檢查猶豫不決。筆者於2016年12月8日至2017年3月31日照護期間，運用吳(2000)的「確定感及不確定感之評估指引」，及Mishel認為患者面臨不確定感主要來源：症狀、醫院常規、治療、醫療小組與個案的溝通等四方面，藉由直接照護、會談、電訪追蹤和病歷查閱等方式進行資料收集，確立個案有害程度之確定感的原因是：對於疾病惡化狀況能預測和面臨血液透析治療的無望、憂鬱；高度不確定感的原因是：治療效果不符合患者期望、對疾病症狀缺乏完整訊息、醫療小組與患者之溝通不明確和面對決策卻猶豫不決。針對個案陷入有害程度之確定感和高度不確定感的威脅及擔憂心肌梗塞復發，筆者除了給予正向支持鼓勵，也提供血液透析治療和心肌梗塞疾病衛教觀念加強個案自我照護，並運用認知再評價的方式改善個案有害程度之確定感，及運用三種個人控制策略來改善高度不確定感，配合良好的支持性系統，讓個案能以正向的心態面對與適應疾病，個案於3月21日至血管外科進行瘻管擴張術，並持續接受血液透析治療。

關鍵字

不確定感 ； 血液透析 ； 心肌梗塞

並列摘要

This article explores the harmful certainties and uncertainties caused by hopelessness and depression alongside complications resulting from myocardial infarction while undergoing hemodialysis in a patient with diabetic end-stage renal disease. These feelings resulted in the patient being indecisive regarding visiting a surgery department for examination of the poor flow rate of a fistula during treatment. Between December 8, 2016, and March 31, 2017, the author of this article cared for the patient and utilized the“ Certainty and Uncertainty Evaluation Guide” by Wu (2000) and the four sources of uncertain feelings in patients as defined by Mishel, namely symptoms, hospital routines, treatments, and communication, between patients and the medical team. Data were collected through direct care, conversation, telephone follow-up, and a review of medical charts. The causes of the patient's detrimental levels of certainty were established as the predictable deterioration of the illness and hopelessness and depression resulting from undergoing hemodialysis. In addition, the causes of uncertainty were established as the treatment outcome not reaching the patient's expectation, a lack of complete information regarding the disease's symptoms, unclear communication between the patient and the medical team, and indecisiveness toward decision making. Regarding the patient's concern of myocardial infarction recurrence, the author provided positive support and encouragement, as well as health education on hemodialysis and myocardial infarction, to enhance the patient's self-care ability. Cognitive reappraisal was used to improve the patient's harmful certainty, and three different self-control strategies were used to improve the high degree of uncertainty. With a well-coordinated support system, the patient was able to accept and adapt to the disease with a positive attitude. On March 21, 2017, the patient underwent a fistula dilatation procedure at the department of cardiovascular surgery and continued to receive hemodialysis treatment.

並列關鍵字

uncertainty ； hemodialysis ； myocardial infarction

參考文獻

吳淑芳(2000)．脊髓損傷病人不確定感之評估與護理．護理雜誌，47(4)，52-58。

孫宜孜、徐邦治、楊福麟、廖晉興、林崇舜、李茹萍(2005)‧血液透析患者之憂鬱狀態及影響因素探討‧慈濟護理雜誌，4(3)，47-55。

Andersen, S. M., & Lyon, J. E. (1987). Anticipating undesired outcomes: The role of outcome cer-tainty in the onset of depressive affect. Journal of Experimental Social Psychology,23(5), 428-443.

Cukor, D., Cohen, S. D., Peterson, R. A., & Kimmel, P. L. (2007). Psychosocial Aspects of Chronic Disease: ESRD as a Paradigmatic Illness. Journal of the American Society of Nephrology, 18(12), 3042-3055.

McCormick, K. M. (2002). A Concept Analysis of Uncertainty in Illness. Journal of Nursing Scholarship,34(2),127-131.