臺灣博碩士論文加值系統

背景：壞死性軟組織感染為罕見、嚴重的感染性疾病，易產生敗血症、休克與器官衰竭，即便患者接受積極的醫療照護，仍可能面臨截肢和死亡，復原時間長，影響患者身心、社會、健康、生活品質與增加國家健保耗費，然而，國際間對此群體之護理健康實務研究十分缺乏。
目的：本研究旨在探討南部某區域醫院罹患壞死性軟組織感染人口學特性、共病症、環境因素與防護行為及感染嚴重度相關因素。
方法：運用南部某區域醫院醫療資訊系統，蒐集2015/01/01至2020/12/31年期間診斷壞死性軟組織感染患者，採用病歷回溯次級資料分析（Retrospective, secondary data analysis），以「研究變項與類型萃取單」作為主要資料來源，輔以「電話訪談問卷」了解患者防護行為及結構式訪談，排除未滿18歲、認知或精神障礙、非病危自動出院者、轉院、死亡個案、細菌培養沒有致病菌增長（No growth）與病理組織切片無筋膜壞死者，重複入院患者以初次發病作為納入條件，避免影響感染嚴重度結果，總計236人納入本研究，資料分析使用SPSS 22.0版統計軟體，運用X2檢定、獨立樣本t檢定（Independent sample t test）、單因子變異數分析（Analysis of variance, ANOVA）、皮爾森積差相關性分析（Pearson correlation analysis）和線性迴歸分析（Linear Regression Analysis）進行推論性統計分析。
結果：依據研究目的進行結果說明：
一、研究對象人口學特性描述結果
本研究NSTI患者群體共236名年齡平均為65.08歲（SD ± 14.95）、男性最多（n=171，72.46%），BMI平均26.39 kg/m2（SD ± 4.82 kg/m2）、農漁養殖業者最高（n=94，39.83%）、國小學歷佔最多（n=140，59.36%），共病症以糖尿病為多（n=106，44.92%），且共病症平均1.10（SD ± .91），夏秋季6-11月感染人次最高（n=150，63.56%），海區感染人次最多（n=158，66.95%），以肢體異物傷害（含挫傷、鈍傷、擦傷、穿刺傷）與非創傷均等（n=118，50.00%）：感染嚴重度結果截肢率10.59%（n=25）、手術次數平均3.00次（SD ± 1.61），住院天數平均34.46天（SD ± 22.10）。
本研究電訪個案共43名，電話訪問群體年齡平均為62.74歲（SD ± 14.93），男性為主（n=34，79.07%）、BMI平均26.89 kg/m2（SD ± 4.01）、農漁養殖業最多（n=20，46.51%），國小學歷佔最多（n=24，55.81%）、共病症以糖尿病為多（n=18，41.86%），且共病症平均1.09項（SD ± 1.04）、夏秋季（6-11月）感染人次最高（n=23，53.49%），居住海區的感染人數最多（n=30，69.77%）、肢體異物傷害佔最多（n=29，67.44%），感染嚴重度之截肢率（n=9，20.93%），截肢1次（n=20），截肢2次（n=5），手術次數平均3.16次（SD ± 1.73），住院天數平均35.60天（SD ± 23.28）。
二、人口學特性與感染嚴重度之相關性結果
本研究之人口學特性與感染嚴重度，以<65歲此族群之截肢人數高於65歲群組（X2=3.97*, p=.05）和教育程度（X2=7.53*, p=.02）有無截肢具統計顯著差異，高中以上學歷截肢人數最多，餘人口學特性之手術次數與住院天數皆未達統計差異。
三、共病症與感染嚴重度之相關性結果
本研究之共病症與感染嚴重度，以有糖尿病患者之截肢次數具統計差異（X2=8.29*, p=.00）及罹患非肝之惡性腫瘤在手術次數具有現統計差異（t=2.01*, p=.05），其餘之共病症與共病症多寡皆不具統計顯著差異。
四、環境因素與感染重度之相關性結果
本研究之環境因素與感染嚴重度皆不具統計顯著差異。
五、電訪對象防護行為與感染嚴重度之相關性結果
手術前後之防護認知由6.98%提升至88.37%，統計呈現顯著差異（t=17.87**, p<.00），但手術前後之防護認知與感染嚴重度未達統計差異。
手術前後之防護技能由11.63%提升至32.56%，統計呈現顯著差異（t=4.50**, p<.00），但手術前後之防護技能與感染嚴重度未達統計差異。
六、人口學特性、共病症、環境因素及防護行為對感染嚴重度之間預測因子分析結果
（一）年齡、BMI、共病症與手術次數、住院天數皮爾森積差相關分析結果
依據研究目的推論連續型自變項與連續型之感染嚴重度依變項預測兩者之間的相關性，結果年齡在手術次數與住院天數變項關聯程度微弱（r=-.11, r=-.05），在BMI、共病症和感染嚴重度中的手術次數與住院天數變項關聯程度微弱（r=.05, r=-.01, r=.04, r=.11）。
（二）職業、教育程度、居住區域與手術次數、住院天數單因子變異數分析結果
依據研究目的檢定三組類別型自變項與連續型之感染嚴重度依變項之間是否具有差異，結果在人口學特性中職業分為家務管理工作、公商服務與農漁養殖三組，此三組進行事後比較，結果在手術次數當中呈現公商服務>農漁養殖>家務管理工作，三組無顯著差異，在住院天數當中呈現公商服務>家務管理工作>農漁養殖，三組無顯著差異，教育程度分為國小、國中與高中以上三組，此三組進行事後比較，結果在手術次數當中呈現國中>高中以上>國小，三組無顯著差異，在住院天數當中呈現高中以上>國小>國中，三組無顯著差異，在環境因素當中居住區域分為山區、屯區與海區三組，此三組進行事後比較，結果在手術次數當中呈現屯區>山區>海區，三組無顯著差異，在住院天數當中呈現屯區>海區>山區，三組無顯著差異。
（三）年齡、教育程度、共病症類別自變項與有無截肢羅吉斯迴歸分析結果
依據研究目的推論類別型自變項與類別型之感染嚴重度依變項預測兩者之間的關係，結果在人口學特性中呈現65歲NSTI患者有無截肢風險是<65歲NSTI族發生截肢風險群機率的0.38倍（OR=.38, 95% CI=.16, 9.1）；教育程度中國小學歷之NSTI1患者是其他學歷有無截肢風險機率高0.34倍（OR=.34*, 95% CI=.15, .81），而在高中以上學歷之NSTI1患者是其他學歷有無截肢風險機率高1.35倍（OR=1.35, 95% CI=.51, 3.60）；共病症有糖尿病患者是無糖尿病患者的有無截肢風險高3.59倍（OR=3.59*, 95% CI=1.44, 8.97）。
（四）共病症、手術前防護技能與手術次數線性迴歸分析
依據研究目的推論類別型自變項與連續型之感染嚴重度依變項預測兩者之間的關係，結果非肝之惡性腫瘤（t=2.01*, p=.05），回歸方程式Y(手術次數)=0.79 X [非肝之惡性腫瘤, 0=無病, 1=有病] + 3.064，罹患非肝之惡性腫瘤之NSTI患者比沒有罹患非肝之惡性腫瘤手術次數高0.79次，在手術前防護技能與手術次數無呈現統計差異（t=1.09, p=.28）。
（五）手術前防護技能與住院天數線性迴歸分析結果
依據研究目的推論類別型自變項與連續型之感染嚴重度依變項預測兩者之間的關係，結果手術前防護技能與住院天數無呈現統計差異（t=1.56, p=.13）。
結論：本研究依循研究結果提出建議未來針對居住台灣南部鄰近海、屯區從事家庭管理工作者、男性、夏秋季（6-11月）、有罹患糖尿病及非肝之惡性腫瘤患者尤為需要加強防護行為，有鑒於防護行為乃預防健康中第一段之衛生教育初級防治，探究手術後防護行為與感染嚴重度失去預防疾病的意義，研究結果在手術前防護技能與手術次數、住院天數無呈現統計差異，手術前後的防護認知與技能在手術後均上升，而在工作環境職場安全與防護裝備功能在手術前後為0%，說明NSTI防護行為在職場衛生安全並未獲得重視且受到輕忽，凸顯未來NSTI衛生教育可由此方面介入改善。
建議成立NSTI病友會，促使NSTI患者提供自身經歷供鄰里學習之警示訊息與學習案例，成為疾病的代言人，以及邀請家屬、社區民眾參與衛生教育教材製作，運用自身感染的經驗和較為相似的價值觀與學經歷，藉由病友會參與衛生教育之教材內容編撰及參閱衛生教育內容是否能提供在地民眾需要之資訊以及探討改變防護技能的解決方案，運用鄰里之間里民傳播該疾病之嚴重性宣導力量，將其內化成個人行為，強化社區行動，以促進個人、家庭與社區的健康，提升公共衛生護理所提倡的第一段初級預防健康中的特殊防護。

Background: Necrotizing soft tissue infection is a rare and severe infectious disease that can lead to sepsis, shock, organ failure, amputation, and death. Even with aggressive medical care, patients may face long recovery times and suffer from physical, social, and mental health impacts, as well as increase healthcare costs. However, there is a lack of nursing and health practical research for this population.
Objectives: This study aims to investigate the demographic characteristics, comorbidities, environmental factors, protective behaviors, and factors related to the severity of infection among patients with necrotizing soft tissue infection in a hospital in southern Taiwan.
Methods: This retrospective, secondary data analysis utilized the electronic medical record system of a hospital in southern Taiwan to collect data from patients diagnosed with necrotizing soft tissue infection between January 1, 2015, and December 31, 2020. A "Research Variable and Type Extraction Form" was used as the main data source, supplemented by a structured telephone interview questionnaire to understand patient protective behaviors. Patients under 18 years old, with cognitive or mental disorders, non-critical against advised discharge cases , transfer to other hospital, death from other disease, no pathogenic growth in bacterial culture (No growth), or no fascial necrosis in pathological tissue sections were excluded from the study. Repeat admission patients were included only for their first occurrence to avoid affecting the severity of infection results. A total of 236 patients were included in this study, and statistical analysis was conducted using SPSS 22.0 software, using inferential statistical analysis such as chi-square tests, independent sample t-tests, analysis of variance (ANOVA), Pearson correlation analysis, and linear regression analysis.
Results: The results are described according to the research objectives:
1. Description of demographic characteristics of study subjects
The 236 patients with NSTI had an average age of 65.08 years (SD ± 14.95), with males being the majority (n=171, 72.46%), and an average BMI of 26.39 kg/m2 (SD ± 4.82 kg/m2). Agriculture, forestry, and fisheries workers accounted for the highest proportion (n=94, 39.83%), and those with a primary school education accounted for the most (n=140, 59.36%). Diabetes was the most common comorbidity (n=106, 44.92%), with an average of 1.10 comorbidities (SD ± 0.91). The summer and autumn seasons (June to November) had the highest infection rate (n=150, 63.56%), and coastal areas had the highest infection rate (n=158, 66.95%). Limb injuries with foreign objects (including contusions, blunt injuries, abrasions, puncture wounds) and non-traumatic injuries accounted for the same proportion (n=118, 50.00%). The amputation rate was 10.59% (n=25), with an average of 3.00 surgeries (SD ± 1.61) and an average hospital stay of 34.46 days (SD ± 22.10).
2. Results of the correlation between demographic characteristics and severity of infection
In this study, there was a statistically significant difference in amputation rates between those under 65 years old and those over 65 years old (X2=3.97*, p=.05), and among education levels (X2=7.53*, p=.02), with the highest amputation rates seen in those with a high school education or higher. There were no statistically significant differences in surgical procedures or hospitalization days based on other demographic characteristics.
3. Results of the correlation between comorbidities and severity of infection
In this study, there was a statistically significant difference in amputation rates among those with diabetes (X2=8.29*, p=.00) and among those with non-hepatic malignant tumors in terms of surgical procedures (t=2.01*, p=.05). There were no statistically significant differences in other comorbidities or the number of comorbidities.
4. Results of the correlation between environmental factors and severity of infection
In this study, there were no statistically significant differences in the severity of infection based on environmental factors.
5. Results of the correlation between protective behaviors and severity of infection through telephone interviews
Protective behavior knowledge increased significantly from 6.98% before surgery to 88.37% after surgery (t=17.87**, p<.00), but there were no statistically significant differences in the severity of infection based on changes in protective behavior knowledge and skills before and after surgery.
6. Results of predictive factor analysis for demographic characteristics, comorbidities, environmental factors, and protective behavior on severity of infection
(1) Pearson correlation analysis between age, BMI, comorbidities and number of surgical procedures and hospitalization days revealed weak correlations between age and number of surgical procedures and hospitalization days (r=-.11, r=-.05), and between BMI, comorbidities, and number of surgical procedures and hospitalization days (r=.05, r=-.01, r=.04, r=.11).
(2) One-way ANOVA was used to test for differences between occupational, educational, and residential factors and the number of surgical procedures and hospitalization days. No significant differences were found between the three groups in terms of the number of surgical procedures and hospitalization days based on demographic characteristics.
(3) Logistic regression analysis revealed that those over 65 years old with NSTI were 0.38 times less likely to undergo amputation than those under 65 years old (OR=.38, 95% CI=.16, 9.1). Among educational levels, those with only elementary school education had a 0.34 times higher risk of amputation than those with other educational levels (OR=.34*, 95% CI=.15, .81), and those with a high school education or higher had a 1.35 times higher risk of amputation than those with other educational levels (OR=1.35, 95% CI=.51, 3.60). Patients with diabetes were 3.59 times more likely to undergo amputation than those without diabetes (OR=3.59*, 95% CI=1.44, 8.97).
(4) Linear regression analysis revealed that patients with non-hepatic malignant tumors had 0.79 more surgical procedures than patients without such tumors (t=2.01*, p=.05). There were no statistically significant differences between protective behavior skills before surgery and the number of surgical procedures (t=1.09, p=.28).
(5) Linear regression analysis revealed no statistically significant differences between protective behavior skills before surgery and hospitalization days (t=1.56, p=.13).
Conclusion: Based on the research findings, it is recommended to strengthen protective behaviors for family management workers, men, those with diabetes or non-liver malignant tumors living in areas near the sea in southern Taiwan, particularly during the summer and fall months (June to November). As protective behavior is the primary prevention of health education, exploring postoperative protective behaviors and the severity of infection is crucial. The study found no statistical difference in preoperative protective skills related to the number of surgeries or hospital stay. However, protective awareness and skills increased before and after the surgery. Additionally, workplace safety and protective equipment had 0% function before and after surgery, highlighting the lack of importance placed on protective behaviors in workplace hygiene. Therefore, future NSTI health education could focus on this aspect to improve protection.
It is suggested to establish an NSTI patient association to encourage patients to provide their own experiences as a warning and learning message for the community. Patients can also become advocates for the disease and invite family members and community members to participate in creating educational materials. Using their in-depth knowledge and experiences, NSTI patient associations can develop and review educational content to provide relevant information to locals. Additionally, exploring solutions to improving protective skills through community engagement can enhance the personal behavior and community action for promoting health for individuals, families, and communities, advancing the primary prevention of public health nursing.

目錄
中文摘要 I
ABSTRACT V
目錄 IX
圖目錄 XII
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究目的 3
第三節 研究問題 3
第四節 研究假設 3
第五節 名詞界定 4
第二章 文獻探討 9
第一節 壞死性軟組織感染疾病概述 9
第二節 壞死性軟組織感染人口學特性與感染嚴重度相關探討 16
第三節 壞死性軟組織感染共病症與感染嚴重度相關探討 18
第四節 壞死性軟組織感染環境因素與感染嚴重度相關探討 20
第五節 壞死性軟組織感染防護行為與感染嚴重度之相關探討 21
第三章 研究方法 24
第一節 研究設計與架構 24
第二節 研究場所與對象 25
第三節 研究工具與變項 29
第四節 研究工具信度與效度 30
第五節 研究步驟 34
第六節 資料整理與分析方法 36
第七節 倫理考量 37
第四章 研究結果 39
第一節 研究對象人口學特性描述 39
第二節 人口學特性與感染嚴重度之相關性 48
第三節 共病症與感染嚴重度之相關性 51
第四節 環境因素與感染嚴重度之相關性 54
第五節 電訪研究對象防護行為與感染嚴重度之相關性 56
第六節 人口學特性、共病症、環境因素及防護行為對感染嚴重度之間預測因子分析 59
第五章 討論 65
第一節 研究對象之人口學特性分析 65
第二節 人口學特性與感染嚴重度分析 68
第三節　共病症與感染嚴重度分析 70
第四節　環境因素與感染嚴重度分析 72
第五節　電訪研究對象之防護行為與感染嚴重度之分析 73
第六節　人口學特性、共病症、環境因素及防護行為對感染嚴重度之間預測因子分析 75
第六章 結論與建議 79
第一節　結論 79
第二節　研究貢獻 80
第三節　研究限制與建議 81
參考文獻 84
中文部分 84
英文部份 86
附錄 92
附錄一　研究變項與類型萃取單 92
附錄二　專家內容效度檢定調查問卷 94
附錄三　電話訪談問卷 97
附錄四　電話訪談問卷專家內容效度問卷 99
附錄五　人體試驗計畫同意書（中文） 102
附錄六　人體試驗計畫同意書（英文） 103
附錄七　電話訪談問卷調查質性訪談 104

表目錄
表2-1 各國NSTI發生率、死亡率、截肢率整理……………………………………...18
表3-1 研究變項與類型萃取單之專家內容效度檢定(CVI)結果……………………...42
表3-2 電話訪談問卷之專家內容效度(CVI)結果……………………..……………….43
表3-3 電話訪談問卷之專家修改意見…………………….………………………….. 44
表3-4 統計分析方法…………………….…………………….………………………..49
表4-1 研究對象人口學特性…………….…………………….………………………..57
表 4-2 電話訪問研究對象人口學特性…………….…………………….………………..59
表4-3 2015-2020年人口學特性與感染嚴重度…………….………………….………63
表4-4 2015-2020年共病症與感染嚴重度…………….…………………….………... 66
表4-5 2015-2020年環境因素與感染嚴重度…………….…………………….………68
表4-6 手術前後防護認知結果統計表…………….…………………….……………..69
表4-7 手術前後防護技能結果統計表…………….…………………….…………..…70
表4-8 2015-2020年研究對象防護行為與感染嚴重度…………….………………… 71
表4-9 研究對象與感染嚴重度皮爾森積差相關分析結果…………….……………...74
表4-10 研究對象與疾病嚴重度單因子變異數分析結果…………….……………….75
表4-11 研究對象與有無截肢羅吉斯迴歸分析結果…………….………………….....76
表4-12研究對象與手術次數線性迴歸分析結果……….………………………..…....77
表4-13 研究對象與住院天數線性迴歸分析結果……….……………………………..77
圖目錄
圖3-1 研究架構圖……………………………………………………………..………....35
圖3-2 G*power 3.1.9.4軟體樣本數計算圖……………………………………..……....37
圖3-3 收案步驟與流程圖………………………………………………………..……....38
圖 3-4 研究流程圖………………………………………………………………………..46
圖4-1 2015-2020年研究對象納入收案說明………………………………………...….56

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