運用個案管理模式照顧一位克隆氏症病人之護理經驗

The Nursing Experience of Using the Case Management Model to Take Care of a Crohn's Disease Patient

本文描述一位初次診斷克隆氏症的青年期男性，經歷疾病症狀反覆求醫過程，正值畢業後邁進入社會工作時，確診疾病必需持續的治療追蹤，除了面臨身體症狀的困擾，影響日常生活作息，心理也擔心發展不良的人際關係，筆者以個案管理模式進行持續性照護，照護期間2020年3月27日至8月13日，運用Gordon 十一項功能性健康型態評估模式，以實際觀察、會談電訪、身體評估、病歷查閱等方式收集資料，確立護理問題有腹瀉、個人因應能力失調、知識缺失。照護期間以資訊疾病管理系統進行，定期追蹤記錄個案狀況，設定1個星期及1個月總共10次門診及電話訪談總共12次，以每次30分鐘為限，依個案面臨狀況作會談時間調整，進行有計劃性的照護，內容包括疾病教育、衛教評值、後續照護、疾病諮詢等；訂定可行性的身心靈為照護目標，加強對疾病相關指導，用藥注意事項，經由對疾病知識的增加，提高對治療的遵從性；同理心支持陪伴，轉變負向情緒，增進對疾病的控制感，學習適應化解危機，以不同角度看待肯定自我，採取正向積極態度，擁有良好人際關係，順利返回生活及職場工作。建議未來臨床舉辦相關個案管理教育，及應主動關懷疾病進展評估與回饋，提供病友會資訊並結合醫院資源，進而提升持續性照護品質，以此提供臨床人員之參考。

This article describes a young man diagnosed with Crohn's disease for the first time. He went through the process of repeatedly seeking medical treatment for the symptoms of the disease. When he entered social work after graduation, he must continue to track the diagnosis of the disease. In addition to the physical symptoms, it affects his daily life. I am worried about the development of bad interpersonal relationships. The author uses a case management model for continuous care. From March 27 to August 13, 2020, the author uses Gordon's eleven functional health assessment models to evaluate the patient. The methods include observation, telephone interviews, physical assessments, review of the medical records for data collection. The author specified the nursing care problems of the patient include diarrhea, emotional coping ability imbalance, and lack of knowledge.
The author used the electronic information system to record and check the patient's status during the period. The author performed a total of 10 outpatient clinic interviews and 12 times of telephone interviews. The meeting time is adjusted according to the situation of the case and limits within 30 minutes. The discussion content includes disease education, health education evaluation, follow-up care, disease consultation, and setup of feasible physical and mental care goals, strengthening disease-related guidance, medication precautions, and learning about diseases.
Through the process, the patient compliance with treatment improved. Through empathy, the patient changes his negative emotions and learns to adapt to resolve crises, looks at self-affirmation from different perspectives, adopts an optimistic attitude, has good interpersonal relationships. The patient returns to his everyday life and works smoothly. It is recommended that clinics organize relevant case management education programs to improve the quality of care. Active nursing intervention is suggested to assessment and feedback on disease progression, Physician-Patient alliance for health information should combine with hospital resources in order to promote continuous health care.