臺灣博碩士論文加值系統

背景：心臟衰竭具高盛行率、高死亡率及高復發率之特性，不僅威脅病人與家屬的健康，反覆住院問題亦造成醫療資源沉重的負擔。病人良好自我照顧行為可以有效改善疾病預後，因此建立連續且完整的照護模式，提供有效策略促進其自我照顧，對於提昇病人照護品質有其重要性。
方法：本研究設計採兩組前後測實驗法，將符合收案條件之心臟衰竭個案隨機分派(randomized clinical trial, RCT)為個管組與控制組兩組。兩組個案均於住院第1-2天收集基本資料及相關重要變項，包括自我照顧行為（含維持maintenance、管理management、自信程度confidence三個面向）、焦慮、憂鬱、自我控制感、自覺社會支持感與健康相關生活品質。控制組只接受醫院常規照護，個管組除接受醫院病房常規照護外，由研究者團隊予以個案管理照護模式介入處置，於住院期間開始即以「心臟衰竭個案健康照護手冊」為衛教工具，提供個案及家屬住院期間的個別性衛教指導，瞭解個案心衰竭自我照顧行為執行過程的困難與相關問題，出院後給予定期諮詢電話3次（出院後第1週、1個月與第2個月），以及門診衛教諮詢服務1次，以因應其個別化需求予以協助。兩組個案於出院後第3個月回診時收集後測資料。介入成效則以無母數t檢定分析檢驗。
結果：共有54名個案完整參與本研究，其中個管組24名（平均年齡54.0±15.8歲；75.0%男性；66.67% NYHA I/II），控制組30名（平均年齡61.1±15.1歲；66.7%男性；90.00% NYHA I/II）。發現實施個案管理照護模式對心衰竭病人能提升自我照顧的維持(Self-Care Maintenance)、自我照顧的管理(Self-Care Management)、自我照護的自信程度(Self-Care confidence)及社會支持感。且證實施行個案管理方式較控制組病房常規衛教可增加個案自我照顧行為之自信程度(confidence)(p<0.05)，但對於自我照顧的維持(Self-Care Maintenance)行為、自我照顧的管理(Self-Care Management)行為、焦慮、憂鬱、自我控制感、自覺社會支持感及健康相關生活品質無顯著差異。
結論：個案管理模式較醫院常規照護能提升心臟衰竭個案自我照顧行為自信程度。本研究設計之個案管理模式可提供醫療機構對心臟衰竭個案持續性品質改善，確實提供以個案為中心的優質照護。

Background: Heart failure is a major health problem and is complicated by high mortality and recurrence rates. Heart failure not only jeopardizes the health of patients and their families, such as repeated hospitalizations, but also imposes a significant burden upon healthcare resources. Sustained, improved patient self-care behaviors and a continuous care model to provide an effective strategy to promote self-care have ensured improvement in the quality of patient care.

Methods: A prospective, randomized, controlled clinical trial was conducted to compare the outcomes of heart failure between patients who did and did not participate in a case management group. Demographic data and critical parameters [self-care behaviors (maintenance, management, and confidence), anxiety, depression, a sense of self-control, perceived social support, and health-related quality of life] were collected at baseline, 1-2 days after admission. Heart failure patients were randomized into a case management group and received case management intervention, including individualized health education guided by heart failure self-care modules. Telephone follow-ups were scheduled for the 1st, 4th, and 8th weeks after the discharge. An outpatient consultation was also scheduled. The patients in the control group only received routine hospital care. All of the outcome assessment data were collected within 3 months of discharge for the case management and control groups.

Results: Fifty-four patients had full participation in this study. Twenty-four patients were in the case management group (mean age, 54.0 ± 15.8 years; 75% male; 67% NYHA I / II), and 30 patients were in the control group (mean age, 61.1 ± 15.1 years; 67 % male; 90% NYHA I / II). Implementation of the case management model of care for heart failure patients included self-care of maintenance, management, and confidence, as well as perceived social support in comparison to the control group (p <0.05). There was no significant difference in self-care of maintenance, conduct, and management, and anxiety, depression, a sense of self-control, perceived social support, and a sense of life without significant differences in health-related quality for both groups.

Conclusion: A case management model can sustain improved self-care behavior and degree of confidence of heart failure patients in comparison to conventional hospital care. This study demonstrated that a case management model can provide continuous quality improvement and high-quality care to heart failure patients.

中文摘要 I
ABSTRACT II
表目錄 VIII
圖目錄 IX
附錄 X
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究目的 2
第三節 研究假設 2
第四節 操作型定義 2
第二章 文獻查證 4
第一節 心臟衰竭介紹 4
第二節 心臟衰竭病人的自我照顧與個案管理模式 8
第三節 心臟衰竭個案管理模式之相關研究 13
第三章 研究方法 19
第一節 研究架構 19
第二節 研究設計 19
第三節 研究資料收集過程 20
第四節 研究樣本 22
第五節 心臟衰竭個案管理模式介入措施 22
第六節 研究工具 25
第七節 研究對象權益與保護 28
第八節 資料統計與分析 28
第九節 研究困難及解決 29
第四章 研究結果 30
第一節 研究對象基本資料 30
第二節 個案管理照護模式對心臟衰竭病人自我照顧行為的影響 33
第三節 個案管理照護模式對心臟衰竭病人焦慮與憂鬱的影響 35
第四節 個案管理照護模式對心臟衰竭病人自覺控制感的影響 35
第五節 個案管理照護模式對心臟衰竭病人自覺社會支持感的影響 35
第六節 個案管理照護模式對心臟衰竭病人健康相關生活品質的影響 36
第五章 討論 38
第一節 心臟衰竭病人基本資料、自我照顧行為、焦慮、憂鬱、自覺控制感、自覺社會支持感、健康相關生活品質之現況 38
第二節 個案管理照護模式對心臟衰竭病人自我照顧行為的成效 41
第三節 個案管理照護模式對心臟衰竭病人焦慮、憂鬱的成效 43
第四節 個案管理照護模式對心臟衰竭病人自覺控制感的成效 43
第五節 個案管理照護模式對心臟衰竭病人自覺社會支持感的成效 44
第六節 個案管理照護模式對心臟衰竭病人健康相關生活品質的成效 44
第六章 結論與建議 46
第一節 結論 46
第二節 研究結果的應用 46
第三節 研究的限制及建議 47
參考文獻 48
一、中文部份 48
二、英文部份 48

一、中文部份
台灣行政院衛生署. (2010). 十大死因統計. http://www.doh.gov.tw/CHT2006/DM/DM2_2.aspx?now_fod_list_no=10072&class_no=440&level_no=3.
江碩儒, et al. (2007). 心臟衰竭治療之新進展. 北市醫學雜誌, 4(9), 908-918.
吳佳蓉, et al. (1997). 心臟衰竭的治療方針. 台灣醫學, 1(1), 104-115.
吳曉雲, et al. (2011). 心臟衰竭患者的疾病知識與自我照顧行為. 護理暨健康照護研究, 7(4), 329-338.
李尹暘, et al. (2007). 自我效能理論之分析與應用. 澄清醫護管理雜誌, 3(2), 46-52.
李麗傳. (2001). 應用個案管理提昇出院準備服務. 護理雜誌, 48(3), 19-24. doi: 10.1097/JNR.0000000000000024
林雅蘋, et al. (2001). 系統性護理指導對心臟衰竭患者疾病知識、態度及自我照顧行為之影響. 慈濟醫學, 13(2), 105-111.
邵榮華, et al. (2010). 自我管理計畫對心臟衰竭老人成效之探討. 志為護理, 9(1), 71-79.
施孟綾, et al. (2010). 心臟衰竭病人之生活品質及其相關因素. 護理雜誌, 57(6), 61-71.
高佳霙, et al. (2008). 全面性照護計畫改善心臟衰竭患者自我照顧、生活品質及再住院之成效探討. 實證護理, 4(3), 233-242.
葉湘芬, et al. (2010). 心臟衰竭老人飲食自我效能與自我管理行為之探討. 志為護理, 9(4), 96-107.
劉敏慧, et al. (2008). 心臟衰竭病患自我照顧能力與症狀困擾、社會支持、憂鬱之研究. 實證護理, 4(4), 277-288. doi: 10.6225/JEBN.4.4.277
劉慧玲, et al. (2010). 心衰竭病人自我照顧的影響因素. 護理雜誌, 57(2), 99-104.
魏嘉儀, et al. (2010). 運用個案管理模式於充血性心臟衰竭住院病患照護之成效. 志為護理, 9(4), 71-83.

二、英文部份
American Heart Association[AHA].(2013).
DeBusk, R. F., et al. (2004). Care management for low-risk patients with heart failure: a randomized, controlled trial. Ann Intern Med, 141(8), 606-613.
Derogatis, L. R., et al. (1983). The Brief Symptom Inventory: an introductory report. Psychol Med, 13(3), 595-605.
Dracup, K., et al. (2003). Perceived control reduces emotional stress in patients with heart failure. J Heart Lung Transplant, 22(1), 90-93.
Fishbein, M., et al. (1975). Belief, Attitude, Intention, and Behavior: An Introduction to Theory and Research. Addison-Wesley.
Harrison, M. B., et al. (2002). Quality of life of individuals with heart failure: a randomized trial of the effectiveness of two models of hospital-to-home transition. Med Care, 40(4), 271-282.
Huang, T. Y., et al. (2013). Moderating effect of psychosocial factors for dyspnea in Taiwanese and American heart failure patients. J Nurs Res, 21(1), 49-58. doi: 10.1097/jnr.0b013e3182828d77
Jaarsma, T., et al. (2013). Comparison of self-care behaviors of heart failure patients in 15 countries worldwide. Patient Educ Couns, 92(1), 114-120. doi: 10.1016/j.pec.2013.02.017
Kasper, E. K., et al. (2002). A randomized trial of the efficacy of multidisciplinary care in heart failure outpatients at high risk of hospital readmission. J Am Coll Cardiol, 39(3), 471-480.
Koelling, T. M., et al. (2005). Discharge education improves clinical outcomes in patients with chronic heart failure. Circulation, 111(2), 179-185. doi: 10.1161/01.CIR.0000151811.53450.B8
Liu, M. H., et al. (2014). A correlational study of illness knowledge, self-care behaviors, and quality of life in elderly patients with heart failure. J Nurs Res, 22(2), 136-145. doi: 10.1097/JNR.0000000000000024
Riegel, B., et al. (2006). Randomized controlled trial of telephone case management in Hispanics of Mexican origin with heart failure. J Card Fail, 12(3), 211-219. doi: 10.1016/j.cardfail.2006.01.005
Riegel, B., et al. (2002). Effect of a standardized nurse case-management telephone intervention on resource use in patients with chronic heart failure. Arch Intern Med, 162(6), 705-712.
Riegel, B., et al. (2008). A situation-specific theory of heart failure self-care. J Cardiovasc Nurs, 23(3), 190-196. doi: 10.1097/01.JCN.0000305091.35259.85
Riegel, B., et al. (2009). An update on the self-care of heart failure index. J Cardiovasc Nurs, 24(6), 485-497. doi: 10.1097/JCN.0b013e3181b4baa0
Shearer, N. B., et al. (2007). A telephone-delivered empowerment intervention with patients diagnosed with heart failure. Heart Lung, 36(3), 159-169. doi: 10.1016/j.hrtlng.2006.08.006
Tsay, S. L., et al. (2002). Effects of perceived self-efficacy and functional status on depression in patients with chronic heart failure. J Nurs Res, 10(4), 271-278.
Vollman, M. W., et al. (2009). Existential well-being predicts perceived control in adults with heart failure. Appl Nurs Res, 22(3), 198-203. doi: 10.1016/j.apnr.2008.02.001
Wade, M. J., et al. (2011). Telemonitoring with case management for seniors with heart failure. Am J Manag Care, 17(3), e71-79.