系統性護理指導對降低血液透析病人血磷值、改善皮膚搔癢與睡眠品質之成效

許多末期腎病接受透析治療的病人為搔癢所困擾，尿毒症搔癢之盛行率大約在50到90%之間，過去20年，不同的假說被提出，其中高磷血症曾被報告與搔癢有關。臨床上對於搔癢症以保濕產品及藥物治療均效果有限。研究證實病人如果沒有正確使用磷結合劑，或未正確選擇適當的食物，會導致高血磷，病人會出現皮膚癢等問題，導致睡眠中斷及生活品質降低。然而目前沒有研究提出是否降低病人的血磷值後，其搔癢情形能夠獲得改善，進而提升睡眠品質。本研究目的在比較接受和未接受低磷飲食及用藥指導方案之病人低磷飲食與磷結合劑用藥知識、飲食中含磷量、血磷值、搔癢與睡眠品質之差異。研究採實驗性研究設計，於2013年9月至12月在台北市某一家醫學中心洗腎室收案，共收案94人。實驗組除常規處置外，接受研究者以衛教手冊為教材，採個別衛教方式之系統性護理指導，並提供用藥提醒小卡使用；控制組只接受常規處置，於後測結束後再予系統性護理指導。研究工具包括：病人基本資料、視覺類比量表、匹茲堡睡眠品質評估量表、低磷飲食與磷結合劑用藥知識量表及飲食紀錄表。研究結果如下: 一、實驗組低磷飲食及磷結合劑用藥知識顯著高於對照組(p<0.001)。二、實驗組病人飲食含磷量顯著低於對照組(p<0.001)。三、兩組病人血磷值之差距差異接近顯著差異(p=0.066)。四、實驗組病人皮膚搔癢情形顯著少於對照組(p<0.001)。五、兩組病人睡眠品質無顯著差異(p=0.635)。六、各變相間的相關性:(1)飲食含磷量與搔癢(r=.371，p <.001)、血磷值(r=.470，p <.001)，血磷值與搔癢(r=.339，p =.001)，血磷值差值與搔癢(r=.250，p =.015)呈顯著正相關。(2)低磷飲食及磷結合劑用藥知識與飲食含磷量(r=-.363，p <.001)、搔癢(r=-.499，p <.001)、血磷值差值(r=-.225，p =.029)呈顯著負相關。研究顯示透過系統性護理指導，以手冊、圖片及提醒小卡，提供病人低磷飲食及磷結合劑用藥護理指導後，病人的低磷飲食及磷結合劑用藥知識提升，飲食含磷量會減少，搔癢情形也會減少。

關鍵字

系統性護理指導；血磷值；皮膚搔癢；睡眠品質

並列摘要

A lot of end-stage renal disease (ESRD) patients under hemodialysis were bothered by pruritus. The prevalence rate of uremic pruritus is between 50 to 90%. In the past 20 years, different hypotheses were proposed. Hyperphosphatemia was reported related to pruritus. In clinical, pruritus could be treated by moisture products and medications with limited response. Previous investigations showed that if patients did not use phosphate binders correctly, or did not correctly choose adequate food, hyperphosphatemia could be resulted in. Pruritus, sleep disturbance and poor life quality may appear. There was no previous report about if reducing serum phosphate level, will pruritus be ameliorated? Will sleep quality of patients get improvement? The aims of this study were to compare the differences between the groups received and did not receive nursing instruction proposal on the knowledge of low phosphate diet and phosphate binders, phosphate amount in the food, serum phosphate level, pruritus and sleep quality of the hemodialysis patients. A quasi-experimental design was carried out. This study recruited 94 patients who received hemodialysis between September 2013 and December 2013 at a medical center in Taipei. Beside regular management, the experimental group received individual systemic nursing instruction by the investigator via a nursing instruction handbook, and a reminding card for medication prescription. The control group received regular management, systemic nursing instruction after the post-test. The following instruments were used, including basic information of the patients, visual analogue scale (VAS), Pittsburg Sleep Quality Index (PSQI), low phosphate diet and phosphate binders medical knowledge scale, and food intake record chart. The results are as following: 1. The knowledge of low phosphate diet and phosphate binders of the experimental group is better than the control group (p<0.001). 2. Food intake behavior of the experimental group is better than the control group (p<0.001). 3. There is nearly significant difference of serum phosphate difference level between the experimental group and the control group (p=0.066). 4. Pruritus in the experimental group is less noted than the control group (p<0.001). 5. There is no significant difference of sleep quality between the experimental group and the control group (p=0.635). 6. The relationship among the variables showed: (1) The phosphate level in the food is significantly correlated with pruritus (r=.371, p<.001), serum phosphate level (r=.470, p<.001), serum phosphate level VS pruritus (r=.263, p=.010), serum phosphate difference level is significantly correlated with pruritus (r=.250, p=.015). (2) The knowledge of low phosphate diet and phosphate binders is significantly negatively correlated with the phosphate level in the food (r=-.363, p<.001), pruritus (r=-.499, p<.001) and serum phosphate difference level (r=-.225, p=.029). This research shows that through systemic nursing instruction, using handbook, pictures and reminding cards, the patients had higher knowledge of low phosphate diet and phosphate binders, the phosphate level in the food decreases, pruritus also decrease.