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系統識別號 U0026-1207201313464000
論文名稱(中文) 探討高齡者住院初次不當留置導尿管之危險因子與結果
論文名稱(英文) Risk Factors and Outcomes for Initial Use of Inappropriate Indwelling Urinary Catheters among Hospitalized Elderly
校院名稱 成功大學
系所名稱(中) 護理學系碩博士班
系所名稱(英) Department of Nursing
學年度 101
學期 2
出版年 102
研究生(中文) 標詩婷
研究生(英文) Shih-Ting Piao
學號 T26001063
學位類別 碩士
語文別 中文
論文頁數 83頁
口試委員 指導教授-陳清惠
召集委員-張家銘
口試委員-施欣怡
中文關鍵字 住院老人  不當使用  導尿管留置 
英文關鍵字 inappropriate use  indwelling urinary catheters  hospitalized elderly 
學科別分類
中文摘要 導尿管留置的住院病人中,以老年人為最多,佔73%,其中高達33%至49%的老人為不當留置導尿管。留置導尿管不僅易產生多項併發症,甚至延長住院天數、增加醫療成本及死亡率。因此本研究目的為探討住院時高齡者不當留置導尿管的危險因子,並分析其相關之影響結果,同時瞭解不當留置導尿管的現況與發生率。本研究採前瞻性研究設計,經人體試驗委員會審查通過後方進行收案,自101年10月29日至102年5月19日,以立意取樣調查台灣南部某醫學中心115位65歲以上之住院且留置導尿管的高齡者。資料收集包含基本人口學特性、Katz日常生活活動量表、簡式老年憂鬱量表、簡易智能量表、察爾森共病症指標與留置導尿管相關資訊等,並於出院時收集相關之影響結果資料,包含住院總天數、出院入住機構等。使用統計軟體SPSS 19.0版進行統計分析,包括百分比、次數分配、平均值、標準差、獨立樣本t檢定、卡方檢定及羅吉斯迴歸分析。
研究結果顯示住院時高齡者不當留置導尿管發生率為37.4%,其中適當留置導尿管因素以「手術需求」最多(43.1%),其次為「需要精確評估尿液輸出量」(37.5%),而不當留置導尿管因素則以「照護方便」最多(62.8%),其次為「急性尿滯留未單導處理」(18.6%)。根據羅吉斯迴歸分析顯示泌尿道感染診斷(OR=7.75, 95%CI=1.84–32.73, p=.005)、認知功能愈差(簡易智能量表分數愈低)(OR=0.77, 95%CI=0.62–0.96, p=.02)及住院時日常生活活動功能愈獨立(Katz日常生活活動量表分數愈高)(OR=1.17, 95%CI=1.04–1.33, p=.012)為高齡者住院時不當留置導尿管之危險因子,且不當留置導尿管將導致出院時日常生活活動功能恢復程度降低(6.72 ± 4.801 vs. 2.44 ± 3.411, p<.001)。
本研究結果不僅瞭解台灣住院高齡者導尿管留置現況,更有助於醫護人員及時檢視患者導尿管使用之適當性,進而降低住院時不當留置導尿管,維護高齡病人之健康與生活品質。
英文摘要 SUMMARY
Inappropriate use of indwelling urinary catheters (IUCs) and their related complications is one of the most important problems in hospitals. The aim of this study was to explore the risk factors and clinical outcomes for initiation of inappropriate urinary catheterization among hospitalized elderly in Southern Taiwan from October 29, 2012 to May 19, 2013. A total of one hundred and fifteen hospitalized elderly who used indwelling urinary catheters during 48 hours after admission were recruited. We reviewed the chart, interviewed the patient, and assessed the need for the urinary catheter daily until the patient was discharged. Data collected included demographic characteristics, co-morbidity, urinary tract infection, urinary incontinence, cognitive function, depression, activities of daily living, unit of catheterization, bed rest order, time of catheters placement, age of caregiver as well as outcomes including catheter-associated urinary tract infection, length of hospital stay, nursing home admission, mortality, and catheters reinsertion. The result indicated that the incidence rate of inappropriate use of IUCs was 37.4%. The diagnosis of urinary tract infection (OR=7.75, p=.005), lower scores of SPMSQ (OR=0.77, p=.02), and higher Katz ADL scores (OR=1.17, p=.012) were risk factors associated with inappropriate indwelling urinary catheterization. Inappropriate catheterized patients also had a poor recovery in activities of daily living at discharge (6.72 vs. 2.44, p<.001). These findings can be provided to clinical care providers and improve the incidence rate of inappropriate catheterization. Education about appropriate indications for indwelling urinary catheters also should be available.

INTRODUCTION
There is approximately 73% of catheterized inpatients are elderly, of which up to 33%–49% are improperly used (Hazelett et al., 2006; Hampton, 2006). Indwelling of urinary catheters is not only associated with prolonged length of hospital stay, increased cost of treatment, but also associates with increased mortality rate, and causes of other complications (Holroyd-Leduc et al., 2007; Inelmen et al., 2007). Therefore, the purpose of this study is to explore the risk factors for inappropriate use of indwelling urinary catheters (IUCs) and determine the association between inappropriate catheters use and outcomes. Furthermore, the incidence rate of inappropriate use of IUCs and the reasons for indwelling urinary catheters use were also explored.

MATERIALS AND MATHODS
The subjects were selected with a purposive sampling method at a medical center in Southern Taiwan. A prospective study was conducted to collect data from hospitalized elders who used IUCs within 48 hours after admission. One hundred and fifteen patients were recruited. Data was collected including: demographic variables, Charlson Comorbidity Index, Katz Index of Independence in Activities of Daily Living, Geriatric Depression Scale Short–Form, Short Portable Mental Status Questionnaire, and information of IUCs placement. The outcomes associated medical care was collected at discharge. SPSS software for windows version 19.0 was applied to analyze the data through descriptive statistic, chi-square, t-test, and binary logistic regression analyses.

RESULTS AND DISCUSSION
The results indicated that the incidence rate of inappropriate use of IUCs was 37.4%. The most frequent indication for catheterization was surgical intervention (43.1%), the second most frequent indication was accurate assessment of urinary output (37.5%). The most common reasons that inappropriate IUCs use was for convenience (62.8%), and used for manage acute urinary retention without assessment (18.6%).

The findings of logistic regression analysis suggested that the diagnosis of urinary tract infection (OR=7.75, 95%CI=1.84-32.73, p=.005), lower scores of SPMSQ (cognitive function) (OR=0.77, 95%CI=0.62-0.96, p=.02), and higher Katz scores (activities of daily living) (OR=1.17, 95%CI=1.04-1.33, p=.012) were risk factors associated with inappropriate IUCs use among hospitalized elderly. Inappropriate catheterized patients also had a poor recovery in activities of daily living at discharge (Figure 1), but were not associated with such outcomes as catheter- associated urinary tract infection, length of hospital stay, nursing home admission, mortality, and catheters reinsertion.

CONCLUSION
Urinary catheters were inappropriately used more commonly among the diagnosis of urinary tract infection, poor cognitive function, and better activities of daily living status in older patients. Careful attention to this aspect of medical care may increase the degree of recovery in activities of daily living at discharge.

Given the significance of these results can help identify groups at increased risk for inappropriate urinary catheters placement. Multiple approaches are needed to reduce inappropriate utilization, including avoiding the placement of unnecessary urinary catheters and education about appropriate indications for indwelling urinary catheters.

ACKNOWLEDGMENTS
The author would like to acknowledge the patients who made this study possible, and thank Prof. Ching-Huey Chen, Fang-Wen Hu, and Dr. Chia-Ming Chang for their help with the design and coordination of this study.

REFERENCES
Hampton, T. (2006). Urinary catheter use often “inappropriate” in hospitalized elderly patients. Journal of the American Medical Association, 295(24), 28–38.
Hazelett, S. E., Tsai, M., Gareri, M., & Allen, K. (2006, October 12). The association between indwelling urinary catheter use in the elderly and urinary tract infection in acute care. BioMed Central Geriatrics, 6(15). Retrieved February 22, 2012, from http://www.biomedcentral.com/1471-2318/6/15
Holroyd-Leduc, J. M., Sen, S., Bertenthal, D., Sands, L. P., Palmer, R. M., Kresevic, D. M., …Landefeld, S. (2007). The relationship of indwelling urinary catheters to death, length of hospital stay, functional decline, and nursing home admission in hospitalized older medical patients. Journal of American Geriatrics society, 55(2), 227–233.
Inelmen, E. M., Sergi, G., & Enzi, G. (2007). When are indwelling urinary catheters appropriate in elderly patients? Geriatrics, 62(10), 18–22.
論文目次 中文摘要 I
英文摘要 III
致謝 VI
目錄 VII
表目錄 IX
圖目錄 X
第一章 緒論 1
第一節 研究背景與重要性 1
第二節 研究目的 2
第三節 研究問題 2
第二章 文獻查證 3
第一節 不當留置導尿管之相關概念 3
第二節 國外不當留置導尿管之研究 7
一、導尿管留置因素 7
二、不當留置導尿管之發生率與危險因子 8
三、不當留置導尿管之影響結果 14
第三節 文獻總結 16
第三章 研究架構 16
第四章 研究方法 18
第一節 名詞定義 18
第二節 研究設計 20
第三節 研究工具的測量 20
第四節 研究過程 23
第五節 研究倫理考量 24
第六節 資料統計與分析 24
第五章 研究結果 27
第一節 人口學屬性 27
第二節 留置導尿管之現況 31
第三節 不當留置導尿管之危險因子 34
第四節 不當留置導尿管之影響結果 45
第六章 討論 50
第一節 住院時高齡者留置導尿管之現況 50
第二節 住院時高齡者不當留置導尿管之危險因子 52
第三節 住院時高齡者不當留置導尿管之影響結果 58
第七章 結論與建議 64
第一節 結論 64
第二節 研究限制與未來研究建議 65
第三節 臨床應用與實務建議 67
參考文獻 68
附錄 75
附錄一 住院時高齡者導尿管留置探討之問卷 75
附錄二 修正凱茲日常生活活動量表 78
附錄三 簡易心智狀態問卷調查表 79
附錄四 老年人精神抑鬱量度表 80
附錄五 查爾森共病症指標 81
附錄六 人體試驗委員會同意臨床試驗證明書 82
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