本篇個案報告主要是引導一位糖尿病多重病變（眼、腎病變）患者如何面對血
液透析過程中所遭遇的生理、心理與社會的問題。護理期間自 2010 年 3 月 20 日至
2010 年 6 月 5 日，筆者藉由身體評估、會談、查閱病歷、家庭訪視、透析紀錄等方
式收集資料，並依生理、心理、社會家庭、靈性等層面進行分析，確立個案的主要健
康問題有：營養不均衡：少於身體所需、情境性低自尊及家庭運作需要協助等。在照
護過程中，筆者運用社工與民間團體的資源，提供個案經濟協助、家事服務並教導個
案日常生活自理技能，以減輕個案的家庭負擔。引導個案建立正向的思考能力、肯定
自己的貢獻，減輕個案的情境性低自尊並重新建立個案家庭運作的效能、改善個案的
生活品質，以達到整體護理的目的。

The subject of this report was a diabetic patient with multiple complications that
received guidance on coping with the physiological, psychological and social problems
encountered during hemodialysis. During the care period between March 20, 2010 and June
5, 2010, data was collected through interviews, physical examination, chart reviews, patient
records, family visits and dialysis records. The data was analyzed to identify the subject's
chief health problems: Imbalanced nutrition: less than body reguiremants, situational low
self-esteem and need for family process. During the care process, the author leveraged the
resources of social workers and private organizations to reduce the pressure on the subject's
family by providing economic assistance, housekeeping services as well as teaching the
patient the skills needed for self-sufficiency. By encouraging the subject to think positively
and acknowledge the subject's own contributions, total care was achieved through reducing
situational low self-esteem, putting the subject’s family situation back in order and improving
the subject’s quality of life.