腦下垂體腫瘤術後病患之症狀困擾與健康狀態之探討

Abstract

腦下垂體腫瘤病患在神經外科手術中屬於第三大族群，主要治療方式為手術摘除，雖然手術能成功地移除腦下垂體腫瘤，但因腦下垂體腫瘤所呈現的症狀非常多樣化，並非手術後皆可改善，包含生理(如，視力模糊、肢端肥大等)與心理(如，憂鬱、焦慮等)的症狀，這些症狀會對病患的生活與工作等方面造成不同程度困擾，且病患術後大多表示不滿意他們的生活，這與我們臨床照護時所見到腦 下垂體腫瘤病患於術後在外觀上即與一般健康人無異之情況有所出入，故引發本研究之目的在於了解腦下垂體腫瘤術後病患之症狀困擾與健康狀態。 本研究採立意取樣，以台北市某醫學中心於民國93年1月至96年4月期間，曾因腦下垂體腫瘤住院接受過手術之90名病患為研究對象，以問卷調查及病歷查閱方式收集資料。研究結果發現，術前最多研究對象經歷且嚴重度最高的症狀為『視力模糊』，而目前研究對象最常見的症狀為『容易感覺疲倦』，嚴重程度最高的症狀為男性個案之『勃起不能』；術後整體症狀困擾改善率約五成，『目前症狀困擾總數』顯著較『術前症狀困擾總數』多(t = 3.54，p = 0.001)，但手術前後症狀困擾嚴重程度間並無差異(t = 0.35，p = 0.727)。個別症狀困擾改善率時間趨勢不同可分為四組，術後一個月內有最明顯改善率(如，視力模糊、頭痛等)；術後半年內(不包括一個月內)有最明顯改善率(如，性慾減低、四肢粗大等)；術後至術後一年以上有漸增加之改善率(如，不想參與社交)；術後至術後一年以上之改善率皆不明顯(如，睡不好、容易疲倦等)，其中以睡不好為改善率最低之症狀困擾項目。研究對象之自覺健康狀態多介於『尚可』與『好』之間，最高分之項目為『比較現在和術後出院時的健康狀況』，最低分之項目為『比較同年齡的人近一年健康狀況』，最受影響之社會功能為『工作』，最不受影響的為『家庭生活』；差異分析結果發現，(1)研究對象之人格特質為樂觀者，其目前症狀困擾總數愈少、目前症狀困擾總分愈低、自覺健康狀態與社會功能狀態皆顯著愈佳，(2)家人支持愈足夠者，其目前症狀困擾總分愈低、自覺健康狀態與社會功能狀態愈佳，(3)對於所接受之護理指導覺得足夠者，其目前症狀困擾總數愈少、目前症狀困擾總分愈低、社會功能狀態愈佳；相關分析結果發現，『自覺健康狀態』與『目前症狀困擾』(r = -0.47，p = 0.000)、『目前症狀困擾嚴重程度』(r = -0.52，p = 0.000)有顯著負相關，『社會功能狀態』與『目前症狀困擾』(r = -0.61，p = 0.000)、『目前症狀困擾嚴重程度』(r = -0.70，p = 0.000)有顯著負相關，而『自覺健康狀態』與『社會功能狀態』(r = 0.46，p = 0.000)間亦有顯著正相關，『目前症狀困擾』與『目前症狀困擾嚴重程度』(r = 0.91，p = 0.000)間有顯著正相關。研究對象自覺健康狀態之預測因子為目前症狀困擾總分(β = -0.35)、家人支持情況(β = 0.28)、人格特質(β = 0.21)，其解釋變異量為35.7 %；社會功能狀態之預測因子為目前症狀困擾總分(β = -0.70)，解釋變異量為48.9 %。 藉由本研究的發現，症狀困擾的數量與程度皆會影響個案之健康狀態，症狀困擾中包括多數個案感到困擾的視力障礙、疲倦、睡不好之問題，與困擾程度高的性功能障礙，對於中年個案在此人生階段中需達到的發展目標-有成就感的工作與美滿的性生活上有所衝擊，故與同年齡人的健康狀態比較顯示健康較不好，但藉由正向因子：增加家人支持、讓個案持有較樂觀之看法與態度、提供充足的護理指導等，皆有利於個案對手術後症狀的管理與整體健康狀態的提昇。期望將本研究結果運用在臨床護理實務上，讓病患獲得更多的資訊，使出院後的生活能有更多準備與更佳調適，也提供臨床醫療照護有更多的依據，提供更切合病患之照護。

Patients with pituitary tumor are the third group in neurosurgical operation. Tumor excision is the major therapeutics for these patients. Surgery can remove tumor successfully; however, leaves in diverse symptoms after surgery. These include physiological (for example, blurred vision and acromegaly) and psychological (for example, depression and anxiety) symptoms that will result in different levels of stress to patients’ lives and works. Most patients don’t satisfy with their lives after surgery, and the phenomena conflicts with what we observe during clinical nursing: patients look as healthy people after surgery. Therefore, the purpose of this study is to understand the symptom distress and health status of pituitary tumor patients after surgery. By purposive sampling, the data from 90 patients experienced pituitary tumor operation from one medical center in Taipei city during January 2004 to April 2007 were gathered by questionnaire survey and medical records review. The study result shows that the most patients experienced and most serious symptom is “blurred vision” before surgery, whereas, presently the most common symptom is “fatigue” , and the most serious symptom is “impotence” among male patients. The total symptom improvement rate after surgery is about 50%. The total number of present symptom is significantly higher than the total number of symptom before surgery (t=3.54, p=0.001). However, there is no significant difference between the levels of symptom distress before and after surgery (t=0.35, p=0.727). Each symptom had different improvement rate, which can be divided into four groups according to different time trend: most obvious improved within one month (for example, blurred vision and headache), most obvious improved within half year (excluding one month) (for example, decrease in libido and acromegaly), steady increasing improved within one year (for example, social isolation) and have no obvious improved over one year after surgery (for example, sleep problems and fatigue). Fatigue has lowest improvement rate among these symptoms. The self-rated health statuses of patients are usually between “fair” and “good”. The highest score one is “compare the health status now and just after surgery”, whereas the lowest one is “compare with the health status of same age people.” The most affected social function is “work” and the less affected one is “family life.” Difference analysis result shows that (1) patients who have optimistic personality have fewer total number of present symptom, lower level of present symptom distress and better self-rated health status and social function, (2) the more the support from family, the lower level of present symptom distress and the better self-rated health status and social function, (3) patients who received enough nursing education have lower level of present symptom distress and better self-rated health status and social function. Correlation analysis shows that there are significant negative correlations between “self-rated health status” and “the total number of present symptom” (r=-0.47, p=0.000), between “self-rated health status” and “level of present symptom distress” (r=-0.52, p=0.000), between “social function” and “the total number of present symptom” (r=-0.61, p=0.000), and between “social function” and “the level of present symptom distress” (r=-0.70, p=0.000). There are significant positive correlations between “self-rated health status” and “social function” (r=0.46, p=0.000), and between “the total number of present symptom” and “level of present symptom distress” (r=0.91, p=0.000). The predictors of patients’ self-rated health status are the total number of present symptom (β=-0.35), family support (β=0.28), and personality (β=0.21). A total of 35.7% of the variance was explained. The predictor of social function is the total number of present symptom (β=-0.70). A total of 48.9% of the variance was explained. From the results of this study, the total number of present symptom and level of symptom distress both affect patients’ health status. Most common symptoms, such as blurred vision, fatigue, sleep problems, and high stressful symptoms, such as sexual dysfunction both impact on the developmental tasks of middle-age patients-work with sense of accomplish and satisfying sexual life. Therefore, patients have worse health status comparing with same age people. However, positive factors, including more family support, optimistic views and ample nursing education, will benefit patients’ self-management of symptom after surgery and promote their health status. We hope the result of this study can be applied on clinical nursing practice, thus patients can have more information that can prepare them more and make them better adapt to the symptom distress after discharged from hospital. The results also provide reference to clinical nursing so that patients can receive more suitable care.