護理介入措施對於高膽紅素血症新生兒成效之探討

Abstract

黃疸是新生兒最常見的問題，約有10%新生兒會成為高膽紅素血症，約有1~4%的新生兒於出生後第一週會因高膽紅素血症再入院。本研究主要在探討「完整的高膽紅素血症新生兒照護指導」護理介入措施對於高膽紅素血症新生兒成效之影響因素，包括新生兒及其母親之特性、入院體重、出院體重、入院膽紅素、出院膽紅素、照光天數、住院天數、餵食型態、大小次數、母乳哺餵量、母乳哺餵時間、配方奶量之變化與影響。 本研究是採回溯式世代研究法(Retrospective cohort study)，針對北區某醫學中心之新生兒中重度病房於施行「完整的高膽紅素血症新生兒照護指導」的護理介入措施前、後各2年期間，即2008年1月至2009年12月（cohort 1：控制組）與2010年1月至2011年12月（cohort 2：實驗組），對出院後14天內再入院的高膽紅素血症新生兒進行護理介入措施成效研究。由研究者於研究醫院的病歷室以病歷閱覽方式進行資料收集，研究工具為研究者經由文獻查證自擬的「高膽紅素血症新生兒及母親基本資料表」及「高膽紅素血症新生兒住院期間資料表」。收案時間自2013年10月7日至2013年11月9日，符合收案條件的對象控制組共得61人，實驗組共有30人。資料以SPSS 20.0套裝軟體進行統計分析，包括描述性統計、卡方檢定(Chi-square test)、獨立樣本t檢定(Independent sample t-test)、費雪精確檢定(Fisher’s exact test)、雪費檢定(Scheffé test)等統計方法。 研究結果發現，施行「完整的高膽紅素血症新生兒照護指導」的護理介入措施後，有助於降低高膽紅素血症新生兒再入院率，由3.86% 降為2.16%。兩組高膽紅素血症新生兒於再入院情形比較，實驗組的「入院體重」（2876.27 ± 463.65公克vs 3123.98 ± 551.37公克, t = -2.12, p =.037）與「出院體重」（2951.87 ± 487.13公克vs 3284.82 ± 559.93公克, t = -2.78, p = .007）皆顯著較控制組輕，「出院膽紅素」值顯著較控制組高（11.50 ± 1.41 mg / dL vs 10.74 ± 1.37 mg / dL, t = 2.47, p = .015），「配方奶量」的攝取顯著較控制組少(323.86 ± 172.75 ml vs 465.12 ± 224.34 ml, t = -2.98, p = .004)。另外，本研究同時發現母親年齡愈長，新生兒住院天數愈少（7.50 ± 0.70天vs 3.79 ± 1.65天 vs 3.44 ± 1.59天, t＝5.407, p＝.011）；母親教育程度越高，新生兒住院天數（8.00 ± 0.00天vs 3.80 ± 2.04天vs 3.33 ± 1.52天vs 3.50 ± 1.54天vs 6.00 ± 1.00天, t＝3.312, p＝.026）及照光天數愈少（8.00 ± 0.00天vs 2.60 ±1.82天vs 2.33 ± 1.53天vs 2.44 ± 1.38天vs 4.33 ± 2.08天, t＝3.941, p＝.013）；母親教育程度為大學其「母乳餵食量」較專科與研究所顯著較多(192.57 ± 80.59 vs 60.00 ± 0.00, 51.33 ± 10.26 respectively, t = 5.031, p = .038)。 本研究護理措施「完整的高膽紅素血症新生兒照護指導」係以家庭為中心之護理理念為基礎而設計的，提供照護者更為完整的新生兒照護。研究發現支持此護理措施的成效，有助於提升母乳哺餵量，降低新生兒配方奶的餵食量，及降低高膽紅素血症新生兒的再入院率，此措施可以提供護理師在照顧上有力的參考指引。

Hyperbilirubinemia is the most common health problem in the neonatal phase. Around 1% to 4% of newborns will be hospitalized again due to this problem in the first week after birth. The research is to explore the effects of nursing interventions on newborn with hyperbilirubinemia within 14 days after being discharged from hospital. These factors includes the characteristics of newborns and their mothers, newborns’ admission body weight, discharge body weight, bilirubin value at admission, bilirubin value at discharge, days of phototherapy, length of hospital stay, feeding pattern, times of output, amount of breast milk feeding, breastfeeding time, amount of formula milk feeding. Data were collected by the researcher herself through chart review. Research tools include self-developed checklists for the demographic characteristics of both newborns and their mothers and the clinical manifestationof newborn babies. All the data were recored in a laptop computer. Investigation period ranged from 2013.10.07 to 2013.11.09. Control group from Jan, 2008 to Dec, 2009. There are 61 newborns in total which got hyperbilirubinemia and need readmitted, Experimental group, in between Jan, 2010 and Dec, 2011, there are 30 newborns who suffered the same symptoms. The SPSS20.0 software was used for the statistics analysis, including methods like description statistics, Chi-square test, independent sample t-test and Fisher’s exact test, and Scheffe test. We found that by providing mothers with complete instructions for taking care of a baby with hyperbilirubinemia during the nursing intervening, it helps reducing the readmission rate of the newborns with hyperbilirubinemia from 3.86% to 2.16%. Decrease infant formula from 465.12 ± 224.34 ml to 323.86 ± 172.75 ml (t = -2.98, p = .004). Comparing the status of readmission, the experimental group was heavier in both admission body weight（2876.27 ± 463.65gm vs 3123.98 ± 551.37gm, t = -2.12, p =.037）and discharge body weight（2951.87 ± 487.13 gm vs 3284.82 ± 559.93 gm, t = -2.78, p = .007）, had higher value in discharge bilirubin（11.50 ± 1.41 mg / dL vs 10.74 ± 1.37 mg / dL, t = 2.47, p = .015）, and has less intake of formula milk (323.86 ± 172.75 ml vs 465.12 ± 224.34 ml, t = -2.98, p = .004) significantly than in the control group. In addition, we found that the older age of the mother, the lenth of hospital stay of the newborn baby is shorter （7.50 ± 0.70 vs 3.79 ± 1.65 vs 3.44 ± 1.59, t＝5.407, p＝.011）. The higher level of mother’s education was, both length of hospital stay （8.00 ± 0.00 vs 3.80 ± 2.04 vs 3.33 ± 1.52 vs 3.50 ± 1.54 vs 6.00 ± 1.00天, t＝3.312, p＝.026）and days of phototherapy were shorter（8.00 ± 0.00 vs 2.60 ± 1.82 vs 2.33 ± 1.53 vs 2.44 ± 1.38 vs 4.33 ± 2.08, t＝3.941, p＝.013）. Mothers with the degree of university had more amount of breast milk feeding than both mothers with high school deploma and graduate degree (192.57 ± 80.59 vs 60.00 ± 0.00, 51.33 ± 10.26 respectively, t = 5.031, p = .038). Based on the concept of family-centered care, the nursing education with complete instruction of taking care of a newborn baby indeed contribute a mother to improve their understanding about correct feeding pattern and observation. Current study support the effect on increasing breast feeding, decreasing formula milk feeding, and reducing the rate of readmission for the infant with hyperbilirubinemia. These findings provide nursing staffs a good reference for nursing care of the newborns.