運用跨理論模式輔助一位糖尿病個案自我管理之護理經驗

Application of the Trenstheoretical Model to a Case with Diabetes Mellitus on Self-Management

本文運用跨理論模式（transtheoretica lmodel; TTM）協助一位門診7歲第二型糖尿病個案建立行為改變之自我管理護理經驗。照護期間從2015/6/17至2016/3/31，筆者採「整體性護理」評估，發現個案有潛在危險性血糖不穩定、血糖自我監測行為未養成等照護問題，分析其行為改變階段處於「準備期」。護理過程中，筆者以個案為中心，依個案基本特性、社會支持特性、健康信念、行為改變階段，掌握可衛教時機（teachable moment），提供符合個案的認知及行為層面需求之改變策略，包括：增進個案疾病營養、血糖自我監測對疾病控制的重要性之認知，強化社會支持資源，透過遠距醫護通訊應用科技，協助個案建立飲食、血糖自我監控計畫，以TTM成功輔助此門診第二型糖尿病老年個案達成疾病自我管理之行為改變目標。

This article applied the transtheoretical model (TTM) to assist a sixty-seven-year-old patient with type IIdiabetes to implementself-management in outpatient department. The process of health care behavior changes took place from June 7, 0 to March , 0 while the author was adopting a “holistic health care＂assessment framework. At the beginning, the patient experienced the problems of potential risk from poor control of blood sugar, did not develop self-monitoring behavior of blood sugar, etc. The analyzed case was in “preparation period＂ of behavior change process.During the intervention, the author followed the principle of 'patient-centered care' to assist the case, by providing the change strategies that meet the cognitive and behavioral needs of the case based on the patient´s basic features, the characteristics of social support, the stage of behavior changes, and made the most of the teachable moment. Perception and strategies for behavior changes were emphasized: knowledge about the disease control, importance of blood sugar self-monitoring, expansion of social support resources. The paperalso discussed how to use long-distance telecommunication technology to help the case to cultivate healthy eating behaviors and blood sugar self-monitoring plan. The TTM successfully assisted the elderly case of type II diabetes from outpatient department to reach the goal of behavior changes in self-management.