延續「腎」命：糖尿病腎病變病人面臨血液透析抉擇之急診照護經驗

An Emergency Nursing Experience of a Patient with Diabetic Nephropathy Facing Hemodialysis Decision-Making

本文旨在分享協助一位糖尿病腎病變個案面對初次緊急血液透析之照護經驗，護理期間自2015年3月8日09:10至16:30，藉由Gordon十一項功能性健康型態為評估架構，運用身體評估、觀察、會談、查閱病歷等技巧收集資料，發現個案有體液容積過量、抉擇衝突的健康問題。個案在被告知需緊急血液透析時，陷入抉擇困境，導致生命威脅，急診團隊透過體液容積過量與抉擇衝突護理原則，降低心肺負荷、增進氧合作用，運用傾聽、關懷、同理心引導個案表達心理感受，逐一澄清錯誤訊息、建立正確的認知，鼓勵個案以正向態度面對既成的事實，引導評估自我需求與期望，下定治療抉擇，繼而緩解其生心理問題，此成功經驗成為筆者撰寫分享之理由。建議急診護理人員在面對抉擇衝突個案時，須以個別需求為導向，運用傾聽、關懷、同理等技巧引導個案分析抉擇困難之因素，重新正向面對問題、解決問題，做出最符合自我期望的醫療決策。期許第一線急診醫護人員能秉持以病人為中心的照護，幫助病人延續「腎」命、延續生命。

This paper describes the nursing experience of assisting a patient with diabetic nephropathy in decision-making regarding the use of a first emergent hemodialysis. The nursing period was from 09:10 to 16:30 on March 8, 2015. We used Gordon’s 11 functional health patterns as the assessment framework and collected data through physical assessment, observations, conversations, and chart review. The health problems included excess fluid volume and decisional conflict. After being informed of the need to undergo an emergency hemodialysis, the patient faced a decision-making dilemma that could pose a life-threatening risk to the patient if prolonged. To help the patient reduce excess fluid volume, the emergency team conducted strategies including reducing cardiopulmonary workload and enhancing tissue oxygenation. In addition, to resolve decisional conflict, we applied listening, attention, and empathy to guide the patient to express inner feelings, correct misconceptions and develop accurate cognition; and encouraged the patient to have a positive attitude toward the established fact, clarified the patient’s own needs and expectations, thereby assisting the patient to make treatment decision and eventually alleviate the physiological and psychological problems. We would like to share this nursing experience and, based on its success, recommend emergency nurses to provide individualized care and apply skills such as listening, attention and empathy to guide patients experiencing decisional conflict to identify the affecting factors, to positively face and solve the problems, and to make medical decisions that best meet their own unique needs. We hope that first line emergency nurses can prolong the life and kidney function of their patients by delivering patient-centered care.