理經驗前言 用跨領域團隊合作照護模式於一位糖尿病結核病患之護理經驗TZU CHI NURSING JOURNAL Volume 12. Number 3. June 2013 第十二卷第三期運理經驗 中文摘要 21 20 6.8%(2012) 1/3 a(2011) 2010 13,237 65 張秀敏黃秋玲 * 2011 11 232012 2 23 ( 2013; 12:3, 120-128) 關鍵詞 : 糖尿病 結核病 跨領域團隊照護 53% 84%(546/654) 65 21 (diabetes mellitus with tuberculosis, DMTB)( 2010) 阮綜合醫療社團法人阮綜合醫院肺結核個案管理師阮綜合醫療社團法人阮綜合醫院疾病管理衛教室組長 * 接受刊載 :2013 年 4 月 21 日通訊作者地址 : 黃秋玲 80249 高雄市苓雅區成功一路 162 號阮綜合醫院電話 :886-7-3351151 轉 2371 電子信箱 :metaedu_lab@yuanhosp.com.tw 3-5 (Leung et al., 2008) ( 2010) 文獻查證 一 糖尿病結核之簡介及照護 (Jeon & Murray, 2008) 7%7% 3.63 (Leung et al., 2008) (interferon-, IFN- ) (Dooley & Chaisson, 2009) DMTB DMTB (RR=2.9) (RR=2.56)(Wang et al., 2009) ( 2010) 5 ( 2009) ( 2005) ( b 2011) 二 跨領域團隊合作照護模式 (2010) (sense the need in the clinical care) (initiate and activate the team) (patient-centered goal setting) (teamwork) (2011) 120 121
用跨領域團隊合作照護模式於一位糖尿病結核病患之護理經驗TZU CHI NURSING JOURNAL Volume 12. Number 3. June 2013 第十二卷第三期運 理經驗2006/3/20 ( 二 ) 心理層面 : 70 2007/1/192011/11/23 1 ( 2 3 / 2011) 2 2011/11/30 12/19X 問題確立及處置護理問題一 : 營養不均衡 : 少於身體需要 (2011/11/23~12/24) (2011) 12/20 12/24 二 整體性評估 2011 11 232012 主觀資料 (2010) 2 23 ( 三 ) 社會層面 : (2007)1970 3 20% (一)生理層面 : 21 170 36 1. 12.5 12.5 2.11/23 Albumin 2.2g/dl albumin 2.9g/dl Hb11.7 g/dl 0.4 mg/dl 護理過程一. 個案簡介及治療過程 3. 72 4. 12 5 1,000 ( 四 ) 靈性層面 : 1. 2. ( 40 ) 8.5% 1,500 3. 2006 4. 122 123
用跨領域團隊合作照護模式於一位糖尿病結核病患之護理經驗TZU CHI NURSING JOURNAL Volume 12. Number 3. June 2013 第十二卷第三期運理經驗 護理措施 84~185mg/dl( (1)12/17 1. 11/231,700 150~314mg/dl) 3.12/24 / 37.5kg4. 55% 233gm17% 72gm 28% 53gm 2. 2. 12/23 11/24 (2)12/20 3. 4.12/1 護理問題二 : 不遵從藥物 : 肺結核 糖尿病用藥 (2011/12/16~/12/24) 12/24 (3)12/21 1. 2. 5. 1-26. 主觀資料 2.12/22 (1) 護理問題三 : 無效性健康維護能力 (2011/11/23~2012/2/23) 12/8 DOTS (2) metformin 3. 7.12/23 1. 2. 1. 2. 1. 12/22 1.12/11 (12/23 ) 1. 12/19 2. (12/24) 2. glucerna 6 / 1,500~1,600 2. 護理措施 護理措施 metformin 1. 1. 1. 12/22 124 125
用跨領域團隊合作照護模式於一位糖尿病結核病患之護理經驗TZU CHI NURSING JOURNAL Volume 12. Number 3. June 2013 第十二卷第三期運 (1). 理經驗 (2).11/25 2.12/23 2/23 40kg( 38 kg)12.8 g/dl( 11.7 g/dl) 6.9%( 8.5%) 黃達夫 (2007).IOM 五大核心能力 跨領域團隊醫療的實踐. 醫療品質雜誌,1 (4), 47-50 黃淑華 林千惠 詹珮君 黃頌恩 楊靖慧 邱展賢(2009). 我國多重抗藥性結核病醫療照護體系介紹. 疫情報導,25(2), 86-95 黃孟娟 (2005). 談肺結核的飲食治療. 高醫醫 訊月刊,25(2),35-38 TB 12/24 580 / 3.1/6 結論與討論 蔡哲嘉 (2011,10 月 ). 跨領域團隊合作訓練課程規劃與教案設計. 於財團法人醫院評鑑暨醫療品質策進會主辦,100 年度跨領域團隊合作照護工作坊. 高雄 : 高雄醫學大學 設中和紀念醫院 Dooley, K. E., & Chaisson, R. E. (2009). Tuberculosis and diabetes mellitus: Convergence of two epidemics. Lancet Infection Disease, 9(12), 737-746. Jeon, C. Y., & Murray, M. B. (2008). Diabetes 1. 2. 12/24 3. 2/23 後續追蹤 參考資料 中華民國糖尿病學會 (2012).2012 糖尿病臨床照護指引. 臺北市 : 糖尿病學會 王憲華 (2010). 跨領域團隊照護之教育訓練. 醫療品質雜誌,4(4),83-85 行政院衛生署疾病管制局 (2011a). 台灣結核病防治年報. 取自 http://www.cdd.gov.tw 行政院衛生署疾病管制局 (2011b). 結核病診療指引第四版. 臺北市 : 行政院衛生署疾病管制局 財團法人醫院評鑑暨醫療品質策進會 (2011). 跨領域團隊合作照護臨床案例討論教案. 臺北市 : 醫院評鑑暨醫療品質策進會 陳美芳 王瑞霞 洪敏男 林立人 黃啟泉 陳淑玲 (2010). 糖尿病結核. 內科學誌, 21,344-349 mellitus increases the risk of active tuberculosis: A systematic review of 13 observational studies. Public Library of Science Medicine, 5(7), 1091-1101. Leung, C. C., Lam, T. H., Chan, W. M., Yew, W. W., Ho, K. S., Leung, G.,...Chang, K. C. (2008). Diabetic control and risk of tuberculosis: A cohort study. American Journal of Epidemiology, 167(12), 1486-1494. Wang, C.S., Yang, C. J., Chen, H. C., Chuang, S. H., Chong, I. W., Hwang, J. J., & Huang, M. S. (2009). Impact of type 2 diabetes on manifestations and treatment outcome of pulmonary tuberculosis. Epidemiology and Infection, 137(2), 203-210. 126 127
理經驗A Nursing Experience of Implementing Inter-professional Practice Model on a Diabetic Patient with Tuberculosis Hsiu-Min Chang, Chiu-Ling Huang* ABSTRACT This article described the nursing experience of implementing inter-professional practice model for taking care of an elderly diabetic patient complicated with tuberculosis, multiple comorbidities and psychosocial problems. The nursing period lasted from November 23, 2011 and February 23, 2012. The authors collected data by means of interviews, phone calls, chart review and inter-professional cooperation meetings. With comprehensive nursing evaluation, we identified several major health problems, including nutrition imbalance (inadequate for body requirement), medication non-adherence, and futile health maintenance. The authors summoned an inter-professional case conference as a communicative platform and, in accordance to the patient s issues, the team reached a consensus on the strategies with the patient and the patient s family on nursing care and drug treatment strategy. We provided a patient-centered nursing plan, which included individualized nutrition intervention, direct observation treatment by health workers, phone reminders and utilizing community resources, to overcome the issues of medication adherence and regular clinical visits. Eventually, the patient s nutritional status, glycemic control and medication compliance improved under the inter-professional practice model. (Tzu Chi Nursing Journal, 2013; 12:3, 120-128) Keywords: diabetes, tuberculosis, inter-professional practice RN, Tuberculosis Case Manager, Yuan's General Hospital; RN, Leader, Disease Manmanage and Health Education Center, Yuan's General Hospital* Accepted: April 21 2013 Address correspondence to: Chiu-Ling Huang, NO. 162 Cheng-Kung 1st Rd., Kaohsiung 80249, Taiwan Tel: 886-7-3351151 ext.2371; E-mail: metaedu_lab@yuanhosp.com.tw 128 TZU CHI NURSING JOURNAL