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系統識別號 U0026-1202201517453400
論文名稱(中文) 住院高齡病人不當使用留置尿管之探討
論文名稱(英文) Exploring inappropriate use of urinary catheters among hospitalized elderly patients
校院名稱 成功大學
系所名稱(中) 健康照護科學研究所
系所名稱(英) Institute of Allied Health Sciences
學年度 103
學期 1
出版年 104
研究生(中文) 胡芳文
研究生(英文) Fang-Wen Hu
學號 ta8001106
學位類別 博士
語文別 英文
論文頁數 88頁
口試委員 指導教授-陳清惠
共同指導教授-張家銘
口試委員-柯乃熒
召集委員-蔡娟秀
口試委員-林惠賢
中文關鍵字 發生率  留置尿管  高齡  結果  相關因子  重置 
英文關鍵字 aged  associated factors  incidence  outcomes  re-catheterization  urinary catheters 
學科別分類
中文摘要 背景: 住院期間留置尿管常被不當使用且易導致許多其他併發症。目前,針對住院高齡病人不當使用留置尿管相關危險因子與結果之研究極為有限。
目的: 針對住院高齡病人於尿管放置當時、持續使用階段與重置三個時期,分別探討不當使用留置尿管之發生率、原因、相關影響因子與可能之臨床結果。
方法: 採縱貫性研究設計,以方便取樣調查65歲以上且入院後24小時內放置尿管之病人。資料收集前,發展留置尿管醫療適應症之檢核表並由研究者使用檢核表辨識留置尿管之適當性。再者,經由病歷與會談收集資料,包含病人與留置尿管特性、過去排泄功能、健康狀態、尿管放置當時的照護情境、重置尿管的情境與尿管留置的主觀知覺。最後,出院時經由病歷與會談收集結果資料,包含死亡率、住院天數、第一次尿管移除的時間、出院時仍留置尿管、尿管導致泌尿道感染、尿管相關併發症、日常生活活動功能衰退與入住機構。
結果: 321位住院高齡病人入院當時不當放置尿管發生率為38.3%,最常見不當放置原因為「方便照護」 (49.6%)。住院高齡病人有慢性便秘、泌尿道感染病史、此次住院接受內科治療、認知障礙、憂鬱症狀與日常生活活動功能較佳為不當放置尿管的高危險族群。夜班與缺乏護理紀錄呈現尿管放置原因亦與不當放置尿管顯著相關。此外,不當放置尿管將導致高齡病人日常生活活動功能衰退。321位住院高齡病人尿管留置總天數為1958天;其中,67%為不當使用留置尿管。最常見不當使用留置尿管的原因亦為「方便照護」。女性、此次住院接受手術、入院當時不當放置尿管、缺乏尿管留置醫療紀錄顯著與不當使用留置尿管相關。住院高齡者增加不當使用留置尿管天數將導致延長住院天數、延遲尿管移除時間、增加出院時仍留置尿管比率、增加尿管導致泌尿道感染與尿管相關併發症發生率、導致日常生活活動功能衰退。在所有住院高齡者中,尿管重置發生率為20.6%;然而,亦高達49.5%為不當重置尿管。
結論: 衰弱高齡病人為不當使用留置尿管的高危險族群,而不當使用尿管又易引發負向的臨床結果。健康照護人員、病人與家屬因對尿管正確使用的忽視,可由不當放置尿管開始,延續至不當使用尿管的時間延長,至移除尿管後又不當重置,導致一連串的惡性循環。欲解決不當使用留置尿管的問題,醫院宜制定相關尿管使用的政策,包含詳細尿管醫療紀錄的規範及病人與照護者(健康專業照護人員與非正式照護者)尿管相關教育課程;以全面提升尿管使用之照護品質。
英文摘要 Background: Urinary catheterization may lead to substantial complications and is often used in hospitals without an appropriate indication. Studies of factors and clinical outcomes associated with inappropriate use of urinary catheters in the elderly population are rare.
Purpose: To explore the incidence, rationales, associated factors and clinical outcomes of inappropriate urinary catheter use in hospitalized elderly patients among three phases: initial urinary catheter placement, urinary catheter remaining, and urinary catheter re-insertion.
Methods: A longitudinal study enrolling patients aged 65 years and older with urinary catheters placed within 24 hours of hospitalization was conducted. Criteria for urinary catheter use were developed to identify inappropriate catheter use. Characteristics of patients and catheter use, voiding function history, health conditions, care conditions related to catheter placement, conditions for urinary catheter re-insertion, and subjective perceptions of urinary catheter use were collected through reviewing medical records and by interviewing patients or their primary caregivers. Mortality, length of hospital stay, time to first removal of catheter, catheter remaining in place at discharge, catheter-associated urinary tract infections (CAUTIs), catheter-related complications, change of activities of daily living (ADLs), and new admission to nursing home after discharge determined as clinical outcomes.
Results: The incidence of initial inappropriate placement of urinary catheters (IIPC) in hospitalized elderly patients was 38.3%. The rationale most often reported for IIPC was “convenience of care.” Factors associated with IIPC were, chronic constipation, a history of urinary tract infection, medical treatment diagnosis, cognitive impairment, depressive symptoms, independence in ADLs, insertion of catheter during evening and night shifts, and lack of nursing documentation of the rationale for catheterization. Patients with IIPC showed greater decline in ADLs. Among 321 patients, a total of 1958 urinary catheter-days were observed, 67% catheter-days were inappropriate. Inappropriate use of urinary catheters occurred mostly in females and surgical patients and was associated with IIPC and lack of medical documentation. “Convenience of care” was the most common rationale for inappropriate use. Increasing inappropriate catheter-days was a significant predictor of longer hospital stay, delayed time to removal of catheters, increased rate of urinary catheterization at discharge, development of CAUTIs and catheter-related complications, and a decline in ADLs. The incidence of catheter re-insertion was 20.6%, of which 49.5% of them were improperly re-inserted.
Conclusions: Older patients are at greater risk of inappropriate use of urinary catheters. Inappropriate use may lead to substantial complications in older patients. The health care professions, patients and their caregivers do not pay attention to appropriate use of urinary catheters, which induces a vicious cycle of inappropriate catheter use. To eliminate inappropriate catheter use, formulating hospital-level clinical policies related to the use of urinary catheters is extremely important and should include concrete regulations for documentation and a specific education protocol for health care professionals, patients and their caregivers.
論文目次 中文摘要.............................................Ⅰ
Abstract............................................Ⅲ
誌謝................................................Ⅴ
Table of contents...................................Ⅵ
List of figures.....................................Ⅷ
List of tables......................................Ⅸ
Chapter 1: Introduction.............................1
1.1 Background......................................1
1.2 Purpose.........................................4
1.3 Research question...............................5
Chapter 2: Literature Review........................6
2.1 Indications for urinary catheter use............6
2.2 Incidence and rationales for inappropriate urinary
catheter use....................................10
2.3 Associated factors of inappropriate urinary catheter
use.............................................14
2.4 Clinical outcomes of inappropriate urinary catheter
use.............................................21
Chapter 3: Methods..................................25
3.1 Definition of terms.............................25
3.2 Research framework..............................27
3.3 Study design and sampling.......................32
3.4 Instruments and measurements....................33
3.5 Data collection and procedure...................37
3.6 Statistical analysis............................41
3.7 Ethic considerations............................44
Chapter 4: Results..................................45
4.1 Characteristics of hospitalized elderly patients and
catheter use....................................45
4.2 Initial inappropriate urinary catheter
placement.......................................47
4.3 Remaining inappropriate use of urinary
catheters.......................................54
4.4 Inappropriate urinary catheter
re-insertion....................................61
Chapter 5: Discussion...............................68
5.1 Initial inappropriate urinary catheter
placement.......................................68
5.2 Remaining inappropriate use of urinary
catheters.......................................72
5.3 Inappropriate urinary catheter re-insertion.....75
Chapter 6: Conclusion...............................78
6.1 Conclusions.....................................78
6.2 Limitations of the research.....................79
6.3 Applications and recommendations for the
research........................................80
Acknowledgments.....................................82
References..........................................83
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