臺灣博碩士論文加值系統

當病人自醫院出院，因疾病未完全復原需居家休養，或體力衰弱，無法外出就醫，而進入居家醫療照護。在居家期間因飲食營養攝食量不足，緩慢的體重減輕出現非預期體重流失，增加營養不良的風險。本研究以北市某區域醫院於收案前二年曾接受過營養師衛教者居家醫療照護者，採立意取樣的質性研究，收案人數7人。
在第一次居家訪視時，經口進食5人、灌食泥狀試驗餐1人、灌食1人，經口進食有4人出院後體重減輕0.15〜6.5公斤/月，經給予營養介入與衛教後，第二次訪視時，經口進食者3人體重增加0.4〜1.9公斤/月、2人減輕0.4〜1.0公斤/月。七名居家醫療病患中，在第1次訪視時，蛋白質攝取量0.73～1.05公克/公斤體重，熱量攝取量17.5～28.0大卡/公斤體重，蔬菜攝取量低於2份/天。居家醫療迷你營養評估，第一次訪視時(N=7)，營養不良3人、具營養不良危險性4人；第二次訪視時(N=6)，具營養不良危險性5人、正常營養狀況1人。
居家經口進食者，出院後體重緩慢持續的減輕，出現非計畫性體重減輕、咀嚼吞嚥困難的營養診斷，主要原因為合適飲食質地，食物份量或種類，餐次調整等飲食營養相關知識不足。故，居家醫療中，雖病患為經口進食者，仍需建立個案資料管理，以轉介照護團隊評估與及時介入。

Discharged patients would need home care if they are frail and disabled to go out for medical care. At the stage of home care, the patients may have insufficient food intake, unintended weight loss, and risks of malnutrition. This qualitative study aimed to explore the home care patients’ nutritional status and dietary intakes, and the facilitators and barriers for a healthy nutritional status. Seven patients were recruited based on intentional sampling from a regional hospital in Taipei City, who had received nutritional care in hospital in the past two years before the interview.
In the first home care visit, five patients had general diet, one had puree test meal, one was on tube feeding. Four of the five patients eating general diet had reduced body weight (BW)0.15〜6.5 kg /month after discharged. Receiving nutrition education and intervention after the first home care visit, at the second visit, three of the five patients eating general diet had gained BW from 0.4 to 1.9 kg /month, and 2 reduced 0.4 to 1.0 kg / month. The 24-hour dietary recall showed that the patients had protein intake 0.73 ~ 1.05 g/kg BW, caloric intake 17.5 ~ 28.0 kcal / kg BW, vegetable consumption less than 2 portions/day. Mini-nutrition assessment (MNA) at the first visit showed that 3 patients were malnourished, 4 had malnutrition risk, and the MNA at the second visit showed that 5 patients had risk of malnutrition, and 1 had normal nutritional status.
After discharge, the patients eating general diet had slowly and continuously reduced body weights, and their nutritional diagnosis included unplanned weight loss, difficulty in chewing and swallowing. These issues may be due to the lack of dietary knowledge regarding food texture, food size or type. This study demonstrated the need of nutritional evaluation for the home care patients.

第一節、醫療與居家營養照護之現況評析 1
一、延續住院照護的居家醫療 1
二、什麼是營養照護 3
三、住院營養照護 5
四、門診營養照護 7
五、長照1.0/2.0 中營養照護 8
第二節、居家營養的重要與需求 10
一、居家醫療依醫療照護需求分類 10
二、居家醫療經口進食者的營養照護需求 10
三、提供居家醫療安全的經口進食的生活 11
第三節、計畫目的 15
第二章 研究設計與方法 16
一、研究設計 16
二、研究工具 18
第三章 結果 25
一、基本資料 25
二、病人之居家飲食情境與營養診斷 25
三、居家醫療的營養評估 34
四、居家安全進食的評估 40
六、質性訪談 42
七、觀察筆記 50
第四章 討論 55
一、營養評估與診斷 56
二、主要照顧者的營養知識與備餐能力 57
三、居家餐食準備內容及影響病人攝食狀況之因素 58
四、居家是社區照護之基礎 61
六、本研究臨床意義 66
七、研究限制 69
八、結論 69

圖目錄
圖 1 醫療連結居家與社區的照護 2
圖 2 營養不良產生生理健康的影響 3
圖 3 營養診斷分類與次分項 5
圖 4 研究收案流程 17
圖 5 醫療到居家期間的體重 35
圖 6出院後到居家訪視的體重變化 36
圖 7居家是社區照護之基礎 62

表目錄
表 1 半結構式問卷 23
表 2居家醫療個案基本資料表 70
表 3 居家照護人員、飲食種類與進食形式 72
表 4 醫療與居家醫療營養診斷彙整 73
表 5 身體質量指數,熱量與營養素的建議與攝取量 74
表 6 居家醫療MNA與營養不良結果 75



附錄目錄
附錄1 收案病人基本資料表 76
附錄2 迷您營養評估表 77
附錄3 EAT 10評估表 78
附錄4 訪談大綱 79

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