運用個案管理流程協助一位糖尿病合併症原住民個案自我照護經驗

Assisting an Aboriginal Patient with Diabetes Complications through Case Management

本文描述糖尿病衛教師運用糖尿病個案管理，照顧一位罹患第二型糖尿病的53歲原住民婦女。護理期間自2011年08月08日至11月11日。運用Gordon十一項功能性健康型態評估，藉由會談、病歷查閱、身體評估及觀察的方式，收集個案主、客觀資料。歸納出個案的護理問題有；糖尿病自我照護認知不是、體重過輕及焦慮的問題。經由糖尿病個案管理的照護流程，針對個案的問題提供個別化的措施：建立個案正確的糖尿病自我照護，改善口腔咀嚼功能及偏食，學會自我注射膜島素及血糖自我監測，減除擔心視網膜病變及初次自我注射膜島素的焦慮。配合定時回診及衛教諮詢，提昇個案自我照護技能與認知，讓個案因體重及血糖控制穩定達到增進健康的目的。筆者希望透過本文護理經驗的分享，提供臨床護理人員照護相關個案之參考。

This article describes a case management experience for a 53-year-old aboriginal woman with type II diabetes mellitus and associated complications. The nursing period was from August 8 to November 11, 2011. The author used Gordon's functional health assessment tool to collect data through the methods of interview, chart review, physical examination, and observation. The identified health problems included insufficient knowledge of self-care, underweight, and anxiety. According to the workflow of diabetes case management, the author provided individualized care interventions, such as educating the patient self-care, improving the patient's chewing ability, assisting the patient in food preference and selection, instructing the patient about self-injecting insulin and self-monitoring of blood sugar. The patient was supported in reducing her anxiety about retinopathy and self-injection. To reinforce the patient's self-care awareness and skill and to control the patient's body weight and blood sugar at target levels, clinic appointments and education consultation were scheduled. The author hopes that this article can serve a reference for other nurses who manage cases with the same diagnosis.