血液透析病人高血磷致合併症及致死率增加，查檢 2011 年 1 至 6 月單位血磷監 測值達成率 64.1％，未達照護閾值引發動機。分析主要因為病人服藥遵從性不佳、食 物攝取疾病認知不足、護理師指導不完整、輔助工具不佳。專案旨在提升血液透析病 人血磷監測值達成率至 70％，經專案小組擬定對策，於 2011 年 9 月 20 日至 2012 年 6 月 30 日實施，包括制定高血磷照護標準規範，使用圖片護理指導工具、腎友飲 食藥物隨身護照等。結果顯示，血磷監測值達成率由 64.1％ 提升至 71.9％，高血磷 病人服藥遵從性由 34％ 提升至 91％。護理師使用完整一致指導工具及病人使用腎友 飲食藥物隨身護照自我監測，可有效提升血液透析病人血磷監測值達成率。

Hyperphosphatemia increases morbidity and mortality rates among patients undergoing maintenance hemodialysis. From January to June in 2011, only 64.1% of patients in our unit reached the target of the phosphate standard which was less than the care threshold. Analysis found that this was probably due to the following reasons: poor drug compliance, insufficient knowledge of food intake, as well as a lack of assistance and facilitating tools from our nursing team. The main purpose of our project was to raise the serum phosphate standard target achievement rate among hemodialysis patients. Through group discussion, we developed several strategies that were carried out from September 20, 2011 through to June 30, 2012. These included setting standards on hyperphosphatemia care, using pictures as care instruction tools, and passports for individual diet and medication. The achievement rate subsequently increased from 64.1% to 71.9%, and drug compliance improved from 34% to 91%. If nurses use the complete instruction tools and patients use the passports to selfmonitor their food and drugs, we can effectively raise the achievement rate for the serum phosphate target among hemodialysis patients.