運用共享決策於一位早期破水且胎兒染色體異常婦女之護理經驗

Nursing Experience on Applying Shared Decision-making in a Woman with Premature Rupture of Membranes and Fetal Chromosome Abnormalities

本文旨為照護一高齡妊娠婦女於妊娠17週因早發性早期破水住院安胎，於治療過程中確診胎兒染色體異常而歷經終止妊娠抉擇之護理過程。照護期間為2020年2月27日至3月26日，筆者透過實際照護、觀察、會談、身體評估、病歷查閱等方式，以生理、心理、社會、靈性四層面之評估，確立個案具「潛在危險性感染」、「舒適型態改變」、「焦慮」、「抉擇衝突」等健康問題。照護過程中協助運用呼吸冥想降低焦慮，持續陪伴與關心促使個案表達安胎治療之感受，此外運用醫病共享決策，使其獲充分醫療訊息且依自我信念選擇持續安胎治療，雖最終因大量出血緊急剖腹生產娩出早產死嬰，但個案表示將堅強面對，重獲生命價值。而現有護理臨床照護內涵多以技能為核心，以致面臨如長期住院、病況複雜、醫療決策困難之臨床情境時，護理人員難以深入評估個案並提供臨床技能外之人文照護，甚至因此易產生情緒耗竭；建議未來遇及如上述高風險個案，適度調整照護人力並儘可能安排固定幾位護理人員輪替提供連續照護，促使對個案之敏察，應用各式護理活動，協助使患者身心安適，渡過漫長之治療歷程，落實以病人為中心之全人照護。

This paper describes the nursing process of caring for a woman of advanced maternal age, admitted to the hospital for miscarriage prevention at 17 weeks of gestation due to premature rupture of membranes. The patient was diagnosed with fetal chromosomal abnormalities in the course of treatment and had to decide whether to terminate the pregnancy. The nursing period was from February 27 to March 26, 2020. Through physical, psychological, social, and spiritual evaluations employing actual care, observation, interview, physical evaluation, medical record review, etc., the author identified the patient has health problems such as“potentially dangerous infection”,“changes in comfort pattern”,“anxiety”,“decisional conflict. During the care process, breathing meditation was used to reduce anxiety, and continuous company and care promoted the patient to express her feelings about the miscarriage prevention treatment. In addition, doctor-patient shared decision-making was adopted to allow the patient to obtain adequate medical information and choose continuous miscarriage prevention treatment according to her own beliefs. Although the patient finally delivered a preterm still-born infant due to an emergency cesarean section for massive hemorrhage, she expressed that she would face it bravely and regain the value of life. The connotations of the current clinical nursing care are mostly skill-centered, which makes it difficult for nursing staff to deeply evaluate the cases and provide humanistic care beyond clinical skills in the face of clinical situations such as long-term hospitalization, complex medical conditions, and difficult medical care decision-making, and it even leads to emotional exhaustion. It is recommended that when encountering such high-risk cases, as mentioned above, the nursing manpower should be appropriately adjusted in the future. Several fixed nursing staff members should be assigned to provide continuous care in shifts as far as possible to facilitate the perceptiveness of the cases. Various nursing activities should be applied to help the patients feel physical and mental comfort, and pull through the long treatment course, thereby achieving patient-centered whole-person care.