運用跨理論模式協助一位心臟衰竭病人健康促進之護理經驗

The Health Care Experience of a Cross-theoretical Model to Assist a Heart Failure Patient

李惠儀(Hui-Yi Li) ； 張玉娟(Yu-Chuan Chang)

《臺大護理雜誌》 15卷2期 (2019/07) Pp. 48-59

https://doi.org/10.6740/NTUHJN.201907_15(2).0006

摘要

心臟衰竭是一種無法治癒的慢性病，故個案需做好健康自我管理，將疾病相關照護活動融入日常當中，以延緩疾病進展，提高生活品質。本文運用跨理論模式，協助一位25歲心臟衰竭個案建立健康促進之護理經驗。護理期間2016年5月24日至7月19日，運用整體性護理評估、觀察、會談及病歷查閱等方式收集資料，確立有「心輸出量減少」、「活動無耐力」、「不遵從（低鈉飲食）」及「個人因應能力失調」等四項健康問題。根據跨理論模式不同改變階段，設定不同目標，提供相關認知及行為改變策略，如護理經驗分享、提供相關指導單張、影片及自編護心手冊等，另與物理治療師及營養師進行跨科部合作，讓個案能有效自行安排運動及飲食計畫，以增進個案建立自我照顧及自我決策的能力。此類個案出院後仍須持續追蹤其健康問題，建議可發展心臟衰竭個案管理師，以利長期追蹤。

關鍵字

心臟衰竭 ； 健康促進 ； 跨理論模式

並列摘要

Heart failure is an incurable chronic disease. Therefore, patients need to incorporate self-management and disease care into daily life to improve the progress of disease and quality of life. This article described an experience of caring for a 25-year-old male patient with congestive heart failure using the transtheoretical model. The nurse took care of this patient from May 24 to July 19, 2016. The patient's major health problems were decreased cardiac output, activity intolerance, noncompliance (low-sodium diet), and ineffective individual coping. According to the transtheoretical model to set different goals in different stages, we offered relevant cognitive and behavior modifications through sharing, heart failure leaflets, video presentation, and self-compiled heart care manual. Physiotherapists and nutritionists for transdisciplinary care were also provided to allowing patients to plan their exercise and diet programs and building self-care and decision-making abilities. Because these patients are required to continue to track their health problems after discharge, it is recommended that a heart failure case-manager be instituted to facilitate long-term follow-up.

並列關鍵字

heart failure ； health promotion