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研究生:曾夢如
研究生(外文):Tseng, Meng-Ru
論文名稱:介入結構式護理對四肢外傷病人之失能、創傷後壓力症狀與生活品質之長期影響
論文名稱(外文):Long-term Effects of a Structure Nursing Intervention among Physical Disability, Post-Traumatic Stress Symptoms and Quality of Life in Patients with Extremity Injuries
指導教授:洪嫦巧洪嫦巧引用關係
指導教授(外文):Hung, Chang-Chiao
口試委員:彭國狄李碧娥黃淑倫洪嫦巧
口試委員(外文):Peng, Kuo-TiLee,Bih‐OHwang,Su-LunHung, Chang-Chiao
口試日期:2020-01-17
學位類別:碩士
校院名稱:長庚科技大學
系所名稱:護理系碩士在職專班
學門:醫藥衛生學門
學類:護理學類
論文種類:學術論文
論文出版年:2020
畢業學年度:108
語文別:中文
論文頁數:78
中文關鍵詞:四肢外傷失能創傷後壓力症狀生活品質
外文關鍵詞:extremity injuriesdisabilitypost-traumatic stress Symptomsquality of life.
相關次數:
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  • 下載下載:22
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背景:隨著醫學與科技的進步,嚴重外傷死亡人數逐年下降且存活率不斷提高,但外傷倖存者的失能比率卻不會因死亡率下降而改善。近年來國內外關於外傷的研究,主要針對其創傷原因、死亡率、住院天數及醫療負擔費用等;對於外傷病人受傷後失能狀況及健康生活品質影響研究,大多探討脊隨損傷或腦損傷病人,關於肢體外傷病人受傷後可能導致的失能、心理創傷症狀,及後續生活品質常被醫護人員忽略或輕估,目前對於外傷後的標準照護模式,比起癌症、慢性末期腎病變或腦中風等疾病,尚未有明確的照護指引或具體發展的成效發表,有鑒於此,本研究制定以實證為基礎的結構式護理措施,希望提供護理人員臨床照護時之依循,以降低外傷病人受傷後產生之生心理症狀,影響後續生活品質。
目的:本研究目的為探討介入結構式護理對四肢外傷病人之失能、創傷後壓力症狀與生活品質之長期影響。
方法:本研究採縱貫性重複測試之類實驗設計,於台灣南部一家設置1,089張病床的區域教學醫院進行收案。研究對象為四肢外傷入院並接受手術治療的病人,參與者的納入標準為:(1)20歲至65歲的四肢外傷病人;(2)創傷嚴重度評分ISS ≥9;(3)任何一處肢體骨折、或骨折合併有軟組織、血管及神經等損傷;(4)意識清醒且簽署同意書者;(5)識字可以填答問卷或經由訪員詢問問題可以清楚答覆者。實驗組的參與者接受了結構性護理措施,包括監測各項生心理併發症、提供自我照顧手冊,以及擬定後續復健計劃等。對照組的參與者則接受了常規護理。以結構式問卷進行資料收集,問卷含社會人口學特性、疾病特性、失能程度評估(Barthel Index in Activities of DailyLiving, BADL、Instrumental Activities of Daily Living , IADL)、創傷後心理症狀指標量表(Post-Traumatic Stress Disorder Reaction Index, PTSD)與台灣簡明版世界衛生組織生活品質量表(The World Health Organization Quality of Life- BRIEF, WHOQOL- BRIEF)。測量時間分別在病人出院時、出院後3個月及6個月。研究資料以SPSS 22.0版套裝軟體進行資料分析。統計方法包括:平均值、標準差、百分比、卡方檢定(Chi-square test)、費雪精確檢定(Fisher’s exact test)、獨立樣本t檢定和成對樣本t檢定(Paired sample t test)模式,以廣義估計方程式(Generalized estimating equations, GEEs),分析實驗組介入結構式護理後,與對照組各量表之差異,包括出院後3個月與6個月,以進行護理措施介入效果確認。
結果:研究對象以男性較多(佔71.1%),平均年齡43.88歲(SD 14.28歲),受傷機轉方面以汽機動車事故最多(佔60.5%),平均住院天數為26.30天(SD = 24.21),受傷肢體AIS平均分數為2.91分(SD = 0.29),ISS平均分數為11.04分(SD = 4.98),NISS平均分數為14.07分(SD = 6.00),另外研究對象有開放性骨折者(佔32.9%),受傷肢體數平均為1.41個部位(SD = 0.57),受傷部分以下肢最多(佔64.5%),另外有合併其他部位多重創傷者(佔35.5%)。兩組研究對象之「巴氏日常生活活動能力BADL」、「工具性日常生活活動能力IADL」、「創傷後心理症狀指標量表PTSD-RI」及「生活品質量表WHOQOL-BRIEF」出院後3至6個月變化情形皆呈顯著差異(p <.001)。接受結構式護理實驗組受試者,在出院後3個月及6個月在各量表得分結果,均優於對照組受試者,但未達顯著水準(p > .05)。再透過廣義估計方程式GEEs模式進行兩組受試者改變幅度差異分析發現,兩組在「巴氏日常生活活動能力BADL(B = -2.72,p > .05)」、「工具性日常生活活動能力IADL(B = -0.81,p > .05)」、「創傷後心理症狀指標量表PTSD-RI(B = -0.01,p > .05)」及「生活品質量表WHOQOL-BRIEF包含生理範疇(B = 0.45,p > .05)、心理範疇(B = 0.22,p > .05)、社會範疇(B = 0.01,p > .05)、環境範疇(B = 0.53,p > .05)」的改變幅度皆不具有顯著差異。
結論:研究顯示介入結構式護理之實驗組無論在出院後3個月或6個月之失能、創傷後壓力症狀與生活品質各量表得分結果,均未達統計顯著差異,但此臨床試驗研究結果,仍可協助臨床護理人員了解與提早預防四肢外傷病人創傷後壓力疾患的形成及避免後期影響。亦可提供發展與測試護理措施之重要參考依據,減少外傷後所造成的身心困擾程度,有助於提升照護品質與降低外傷醫療成本。
Background: With the progress of medicine, science, and technology, the death rate due to traumatic injuries gradually declines and the survival rate continues to increase. Recent studies about traumatic injury focus on the causes of the injuries, mortality, length of hospital stay, and medical expenses. Disability, psychological symptoms, and post-traumatic quality of life for the patients with traumatic injury are often overlooked.
Purpose: The aims of this study were to investigate the long-term effects of interventional structured nursing care on the disability, post-traumatic stress symptoms and quality of life for the patients with extremity traumatic injuries.
Method: A two-groups comparison with repeated measure design was used. A regional teaching hospital of 1089 patient beds, located in the northern part of southern Taiwan was used for this study. The patients who admitted to hospital because of extremity traumatic injuries and had to receive surgery were the research objects. The inclusion criteria for the participants were: (1) aged 20–65 years old with extremity traumatic injuries.; (2) Injury Severity Score (ISS)≧9; (3) any extremity fracture with soft tissue, vessel, or nerve injury; (4) conscious clear and willing to provide informed consent; (5) have an understanding of written and spoken Mandarin or Taiwanese. The participants in experimental group were received interventional structured nursing care which consisted of monitoring physical and mental complications, providing self-care instruction manuals, and developing rehabilitation plans. The participants in the comparison group were received general routine care. The date collection instruments included socio-demographic characteristics, disease characteristics, degree of incapacitation (Barthel Index in Activities of DailyLiving, BADL),Instrumental Activities of Daily Living(IADL), post-traumatic psychological symptom indicators (Post-Traumatic Stress Disorder Reaction Index) and Taiwan concise version of the World Health Organization quality of life scale (WHOQOL-BRIEF). Data were collected at the day of discharge and 3 and 6 months after discharge. Analysis began with descriptive statistics, followed by tests of the research questions by using t-test, Fisher ’s exact test, and generalized estimating equation (GEE). The conventional level of α < .05 was used to represent statistical significance.
Results: A total of 76 participants (experimental group: n =39; comparison group: n =37) enrolled into final analysis. Seventy-one percent of respondents were male, with an average age of 43.88 years (SD =14.28). No significant difference was observed between the two groups according to demographic characteristics, length of hospital stay, score of abbreviated injury scale (AIS), injury severity score (ISS), or new injury severity score (NISS). The finding showed that BADL, IADL, PTSD-RI, and WHOQOL-BRIEF in the two groups gradually increased from 3 to 6 months after discharge (p <.001); however, the results of comparison between two groups showed no significant difference either 3 or 6 months.
Conclusion The results showed that the interventional structured nursing care has no obvious effects on disability, post-traumatic stress Symptoms, and quality of life in patients who undergo extremity traumatic injuries. Some study limitations have been discussed and further study recommendations are provided.
目次
誌謝 I
中文摘要 II
ABSTRACT IV
目次 VI
表目次 VIII
圖目次 IX
第一章 緒論 1
第一節 研究動機 1
第二節 研究問題 3
第三節 研究目的 3
第四節 研究假設 3
第二章 文獻探討 5
第一節 四肢外傷 5
第二節 四肢外傷對病人之影響 12
第三節 生活品質 16
第四節 結構式護理 18
第三章 研究方法 20
第一節 研究概念架構 20
第二節 名詞定義 21
第三節 研究場所與對象 22
第四節 結構式護理介入措施 23
第五節 研究步驟 25
第六節 研究工具 27
第七節 研究對象權益與保護 29
第八節 資料處理與統計分析 29
第四章 研究結果 31
第一節 研究對象基本屬性與疾病特性之分布情形及同質性 31
第二節 兩組個案在在失能、創傷後壓力症狀與生活品質上之差異情形 35
第三節 研究對象於出院後3至6個月在在失能、創傷後壓力症狀與生活品質之差異情形 37
第四節 兩組研究對象於出院後3至6個月在在失能、創傷後壓力症狀與生活品質變化之差異 39
第五章 討論 46
第一節 研究對象基本資料屬性及疾病特性之分析 46
第二節 結構式護理介入對研究對象「失能程度」之成效探討 47
第三節 結構式護理介入對研究對象「創傷後壓力症狀」的成效探討 48
第四節 結構式護理介入對研究對象「生活品質」的成效探討 50
第六章 結論、限制與建議 53
第一節 結論 53
第二節 研究結果與臨床應用 53
第三節 研究限制及未來研究建議 55
參考文獻 57
中文部分 57
西文部分 59
附錄 70
附錄一 臨床試驗變更案同意證明書 70
附錄二 巴氏量表 71
附錄三 工具性日常生活活動能力量表(IADL) 72
附錄四 創傷壓力反應量表 74
附錄五 生活品質量表 75
附錄六 結構式護理清單 77

表目次
表3- 1 研究設計 21
表3- 2 結構性護理介入內容 23
表4- 1 兩組研究對象在個人基本資料之分布情形與差異性 33
表4- 2 兩組研究對象在個人疾病特性連續變相之分布情形與差異性 35
表4- 3 兩組研究對象在個人疾病特性類別變項之分布情形與差異性 36
表4- 4 兩組研究對象於出院後3個月在各研究量表之差異性 36
表4- 5 兩組研究對象於出院後6個月在各研究量表之差異性 37
表4- 6 實驗組個案於出院後3至6個月在各研究量表之差異性 38
表4- 7 對照組個案於出院後3至6個月在各研究量表之差異性 39
表4- 8 兩組研究對象BADL、IADL及PTSD-RI在兩次測量時間點上之差異 40
表4- 9 兩組研究對象在BADL、 IADL及PTSD-RI改變幅度差異 41
表4- 10 兩組研究對象在生活品質(WHOQOL-BRIEF)各範疇在兩次測量時間點上之差異 43
表4- 11 兩組研究對象在WHOQOL-BRIEF生活品質改變幅度差異 44

圖目次
圖3- 1 研究架構 20
圖3- 2 研究流程圖 26
圖4- 1 收案流程 32
圖4- 2 兩組研究對象於出院後3至6個月在BADL之改變情形 41
圖4- 3 兩組研究對象於出院後3至6個月在IADL之改變情形 42
圖4- 4 兩組研究對象於出院後3至6個月在PTSD-RI之改變情形 42
圖4- 5 兩組研究對象於出院後3至6個月在生活品質之改變情形 45



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