The learning in the practices of the students who care the disturbance of consciousness patients from the analysis of their process

意識障害患者を学生に受け持たせ，看護過程の展開の実習を行った．実習終了後の学生の学びを内容分析した結果，看護基礎教育で必須に学ばなければならない清潔などの基本的技術項目や合併症の予防や，意識障害患者に必要な観察や回復支援方法やその大切さを学んでいた．さらに，モデリングとしての看護師の実施するケアの気づきや，学習後の充実感や達成感，患者が回復する事の喜びなどがあった．また，コミュニケーションや状態把握の難しさも学びとして表現していた．このように，意識障害患者を受け持つことで，多くの学習内容を学べることが明らかとなった．We make my students care the disturbance of consciousness patients. This study examines their practice developments by watching their process and analyzing their reports. They learned the followings : （１）The basic technical items（ex. the importance of the cleaning）and the prevention of the complication. （２）How to observe and support the disturbance of consciousness patient. （３）The existence of the nurses as modeling. （４）the emotional reactions such as the fulfillment, the accomplishment and the pleasure after caring and learning. （５）The difficulty to communicate with the patients and to grasp the situations. This result shows how necessary the students care the disturbance of consciousness patients because they learn many points

Management of Apert Syndrome

Aim and objective: To present an Apert syndrome patient with midfacial growth deficiency treated with Le Fort III distraction osteogenesis and subsequent two-jaw surgery. Background: Apert syndrome is expressed as a severe and irregular craniosynostosis, midfacial hypoplasia, and symmetric syndactyly in the fingers and toes. For craniosynostosis syndromes, treatment planning is complex due to the disharmony between facial profile and occlusion. Case description: A 4-year-and-5-month-old boy, diagnosed with Apert syndrome, showed a concave profile accompanied with midfacial hypoplasia, moderate exorbitism, a reversed occlusion of −10.0 mm, an anterior open bite of −5.0 mm, and skeletal class III jaw-base relationship. The patient, aged 15 years and 4 months, underwent a Le Fort III osteotomy, and subsequent osteodistraction was performed via a rigid external distraction (RED) device. His midfacial bone was advanced by approximately 7.0 mm. One year after the distraction, preoperative treatment with 0.018-in preadjusted edgewise appliances was initiated. Two-jaw surgery with a Le Fort I osteotomy and bilateral sagittal split ramus osteotomy was performed after 42 months of preoperative orthodontic treatment. At the age of 20 years and 9 months, his facial profile dramatically changed to a straight profile, and an acceptable occlusion with an adequate interincisal relationship was obtained. A functional occlusion with an excellent facial profile was maintained throughout the 2-year retention period, although the upper dental arch width was slightly decreased, resulting in the recurrence of the left posterior crossbite. Conclusion: Our report indicates the necessity of long-term follow-up in patients with craniosynostosis because of syndrome-specific growth and methodologically induced relapse. Clinical significance: The two-stage operation combining early distraction osteogenesis and postgrowth orthognathic surgery proves to be an effective therapy for correcting midfacial hypoplasia and skeletal mandibular protrusion caused by Apert syndrome

Learning of the students who have undertaken the patients necessitating rehabilitation

運動機能障害や意識レベルの障害があり，リハビリテーション看護の必要な患者を受け持った学生の実習終了後のレポートより，学生の学びを抽出し，内容分析を行った．その結果，２０３コードが抽出でき，３９サブカテゴリー，１０カテゴリーに分類できた．その内容は『リハビリテーション看護の方法の理解と必要性の自覚』，『患者の状況・把握の重要性と判断の難しさ』，『リハビリテーションの必要な患者の思い』，『看護師としての役割の自覚』，『看護のやりがいの実感』，『医療者の連携の重要性』，『家族への援助の必要性』，『コミュニケーションの重要性と難しさ』，『安全確保の重要性と難しさ』，『説明・指導・教育の重要性と難しさ』であった．この中で『リハビリテーションの必要な患者の思い』，『看護のやりがいの実感』，『安全確保の重要性と難しさ』，の３つが，リハビリテーション看護の必要な，運動機能障害や意識レベルの障害がある患者についての特徴的な学びであることがわかった．The learning of the students who experienced rehabilitation nursing of patients having disturbance of motility and/or impairment of consciousness was analyzed from their reports after the clinical practice. As the result, ２０３ codes were extracted and classified into ３９ sub categories and １１ categories. The categories were “understanding of the method of the rehabilitation nursing and consciousness of its necessity”, “importance of the grasp and difficulty of the judgment of the patient situation”, “thought of the patients who need rehabilitation”, “consciousness of the role as a nurse”, “necessity of the assist to the family”, “actual feeling of worth doing of the nursing”, “importance of the cooperation of the medical person”, “importance and difficulty of the communication”, “importance and difficulty of safety ensuring”, “importance and difficulty of explanation, guidance and education”, and “others”. It was found that the knowledge obtained through the rehabilitation nursing was mainly characterized with “importance of safety ensuring”, “thought of the patients”, and “actual feeling of worth doing of the nursing”

臨地実習での学生自己評価 : 興味ある課題導入の有無による比較

臨地実習での学びを効果的にするために，３年課程３年次学生を対象に臨地実習固有の学習内容を用いた学生自己評価を継続しているが，自己評価得点は，実習開始前から中期にかけて上昇しても，中期から終了時には上昇しない傾向が続いた．そのため，成人看護学臨地実習（急性期）では，２００３年度後期に学生の興味・関心のあるテーマを課題学習として導入することを試みた．課題学習を導入した２００３年度後期（３６人）と導入しなかった２００１年度後期（３４人）の自己評価得点の差を統計的に検定することにより，課題学習の効果を検討した．その結果，以下の結果が得られた． ① 課題学習のテーマを決定する過程において，学生は，自己の学習状況を振り返り，整理することができた． ② 終了時の自己評価では，課題学習を導入しなかった２００１年度では４．０点以上の高得点の項目が２０項目であったのに対し，課題学習を導入した２００３年度では４０項目もあり，学生は学習内容に到達したと高く評価していた． これらのことより，興味・関心のあるテーマを課題学習として導入することは，学生の自発性を高め，学習内容に対する学生の到達度の認識を高める可能性があると考えられた．Objective : The purpose of this study was to assess the nursing students' recognitions of their achievement degrees for their educational goals in the clinical practices and discuss the effect of setting students the assignments of themes in which they had interested in the clinical practices. Methods : We used the self-evaluation questionnaire（６２ questions）. Self-evaluation was performed three times ; the first was before the clinical practice, at the middle point of the clinical practice and after the clinical practice. And we set the students assignments in which they had interested in the clinical practices at the middle point in２００３．And we didn't set them in２００１．Then we compared２００３with２００１，and we tested for equality between two means（p＜０．０５）． Results : １．The students assessed their clinical practices when they decided their own themes of assignments. ２．In the final evaluation, the students recognized they achieved their educational goals in４０items in２００３， though there were only２０items in２００１． Conclusion : These results suggest that it may be effective to set the students assignments of themes in which they had interested and that their arrival degrees may be raised by these programs

乳癌縮小手術患者の術式選択時の情報提供のための回復過程の比較

乳癌患者が術式選択を行う場合の情報提供の資料とすることを目的に，乳房温存術（温存術）・胸筋温存乳房切除術（切除術）を受け，術後回復状態を３カ月間縦断的に観察しえたケース３９例において，温存術群（２１例）と切除術群（１８例）の２群にわけ，その２群間の比較を肩関節可動域・握力・創部ドレーン抜去日・胸部の疼痛と日常生活動作で行った．その結果，肩関節可動域は，切除術群・温存術群ともに，前方挙上，後方挙上・側方挙上のすべてにおいて統計的に有意差を認めなかった．しかし，術後１週目には温存術・切除術ともに肩関節可動域は一番低下し，その後３カ月をかけ徐々に回復する経過をたどった．一方，握力は，切除術群の２週目に有意に低下し，切除術は上肢筋力に関して手術侵襲の影響がみられた．術式別の創部ドレーン抜去日および日常生活動作においては，有意差はなかった．術後４週目の創部の動作時の疼痛が，切除術群に比べ温存術群においては「ある」と回答したものが多く，放射線療法による影響が考えられた．乳癌術前患者の術式選択に際しては，単に生存率のみの情報だけでなく，２つの術式には術後の肩関節可動域の制限の程度には差がないこと，温存術に比べ侵襲の比較的大きい切除術では術後２週目に握力の低下を認めること，放射線療法をおこなう温存術では創部の動作時の疼痛の認める例があることなどの，術式により回復のプロセスの違いがある点も情報提示し，対象者のライフスタイルに合わせた術式選択が可能となるよう支援していくことが重要であると考える．The present study was undertaken to collect data to be utilized for informed choice of operative procedure by patients with breast cancer. The subjects of this study were 39 patients who were followed for 3 months after breast-conserving surgery (the breast conserving group, 21 cases) or pectoral muscle-conserving mastectomy (the mastectomy group, 18 cases). The shoulder joint ROM (range of motion), grip, length of time until withdrawal of the drain, chest pain and activity of daily living (ADL) were compared between the two groups. There was no significant difference in shoulder joint ROM in any direction (anterior, posterior or lateral elevation of the joint) between the breast conserving group and the mastectomy group. In both groups, the shoulder joint ROM was minimal one week after surgery and later recovered gradually over 3 months. Grip was significantly lower in the mastectomy group two weeks after surgery, as compared to the breast-conserving group, suggesting influence of operative stress on the arm muscle strength in the mastectomy group. In terms of the ADL and the length of time from surgery to withdrawal of the drain, there was no significant difference between the two groups. Four weeks after surgery, a higher percentage of patients in the mastectomy group answered to have pain during motion of the surgical wound, as compared to the breast-conserving group, probably reflecting the influence of radiotherapy. These results suggest that when providing information to patients with breast cancer to allow selection of an operative procedure, information should be provided not only concerning expected survival rates, but also about similarities and differences in postoperative recovery between the two procedures, including for example the following information :（1）the degree of restriction of shoulder joint ROM does not differ between the two procedures ; （2）grip may decrease two weeks after pectoral muscle-conserving mastectomy which is more invasive than breast-conserving surgery ; and（3）pain during motion of the wound is sometimes complained after breast-conserving surgery which is combined with radiotherapy. It seems essential to help individual patients select a procedure tailored to their life style on the basis of these pieces of information

乳癌縮小手術患者の肩関節可動域の回復遅延に関わる要因の分析

本研究は，乳癌で胸筋切除を伴わない縮小手術を受けた患者の肩関節の可動域の回復遅延ケースにおける，回復遅延に関わる要因を明らかにし，術後の機能回復訓練時の患者指導に活かすことを目的とした．対象は乳房温存術や胸筋温存乳房切除術を受けた乳癌術後患者３９名で，機能回復訓練を術後１２週間縦断的に観察しえたケースにおいて，肩関節可動域の回復状態を良好群と遅延群の２群にわけ，その２群間の比較を，肩関節可動域や疼痛・日常生活動作から観察した．その結果，遅延群ケースから肩関節可動域の回復に関わる主要因として，創部の動作時の疼痛が考えられ，２つめの要因としてこの動作時の疼痛の発生により術後必要とされる運動を行わないことで，さらに回復を遅延させていることが考えられた．よって，動作時の疼痛を訴え，肩関節可動域の回復の遅れを認める例には，機能回復訓練状態の観察と術後１２週目までの継続的な運動の必要性の指導のほかに，肩関節可動域訓練を看護師が患者とともに一緒に行うという確実な実施が，肩関節の可動域の回復遅延の予防となると考えられた．The present study was undertaken to identify factors responsible for delay in recovery of the shoulder joint ROM (range of motion) after minimally invasive surgery for breast cancer (i.e., surgery not involving pectoral muscle excision), with the goal of facilitating better postoperative rehabilitation. The subjects of this study were 39 patients who were followed during 12 weeks of functional rehabilitation after breast-conserving surgery or pectoral muscle-conserving surgery for breast cancer. They were divided into the good recovery group and the delayed recovery group according to the smoothness in recovery of shoulder joint ROM. Shoulder joint ROM, pain and activity of daily living (ADL) were compared between these two groups. Analysis of the data from the delayed recovery group allowed us to identify the pain during movement of the surgical wound as a leading factor affecting the recovery of shoulder joint ROM. Failure to practice exercise after surgery due to pain during motion of the wound was identified as the second leading cause for delayed recovery. These results suggest that in cases where postoperative recovery in should joint ROM is delayed, recovery may be facilitated by monitoring the progress of rehabilitation, advising the patient to continue exercise until day 12 after surgery and guiding the patient to practice shoulder joint ROM training with the help of the nurse

A study on self-efficacy which students have just before graduation ; a comparison between students of nursing universities and those of junior colleges

看護学生の卒業直前の自己効力感を明らかにし，入職後の教育や指導などへの示唆を得る目的で，看護大学４年生と看護短期大学３年生に一般性自己効力感尺度による調査を行った．その結果，看護学生の自己効力感は一般学生よりも高く，大学生は短大生よりも高い傾向が認められ，入職時には自己効力感をより高める教育や指導の重要性が示唆された．We conducted a survey of fourth-year students at a university nursing program and third-year students at a nursing junior college, using a general self-efficacy scale. Our purpose was to investigate self-efficacy beliefs among nursing students immediately before graduation and find out what sort of education and guidance should be offered to nurses after they are employed. This survey revealed that nursing students has higher self-efficacy belief than other university students and that self-efficacy tended to be even higher among university nursing program students than among junior college nursing students. The result suggest that education and guidance are important for improving even more the self-efficacy of newly employed nurses

Effects of intervention with lying hip raise exercises to prevent disuse muscle atrophy in post-stroke patients

The present study measured lower extremity muscle mass using DXA （Dual energy X-ray Absorptiometry） in order to verify the effectiveness of intervention with a series of movements, including lying hip raise exercise with bent knees pointing upwards, among bedridden patients with post-stroke hemiplegia in the acute post-stroke period. Subjects in the intervention group were required to perform １０ repetitions of a series of back-lying exercises once a day with researchers, in addition to the exercises performed by those in a control group. The first measurement of muscle mass was conducted at three to five days after onset, and the second measurement was conducted seven days after the first. Muscle mass in the lower extremities was reduced by approximately ６００g （decrease rate ： ９％）on the paralyzed side and by ２８０g on the non-paralyzed side（decrease rate： ５％）in one week in the Brunnstrom stage ≤ II subgroup（site of measurement : lower extremities） （n＝８） of the control group （n＝２３）. The decrease in muscle mass in the Brunnstrom stage ≤ II subgroup （n＝４） of the intervention group （n＝１５） was approximately ２６０g on the paralyzed side （decrease rate ： ５％） and approximately ２８０g （decrease rate ： ５％）on the non-paralyzed side. Thus, muscle mass decreased on both sides, and this occurred regardless of degree of paralysis. Comparison of the Brunnstrom stage ≥ III subgroups between the control and intervention groups also confirmed that the decease in muscle mass was smaller in the latter group. Thus, it was confirmed that back-lying exercises combining lower extremity movements, including hip raises with bent knees pointing upwards, prevented the decrease in lower extremity muscle mass on the paralyzed side in post-stroke patients. The present study also suggests that these exercise movements can be applied to preventive care for bedridden patients with other severe diseases

Changes in lower extremity muscle mass among with post-stroke hemiplegia

The present study analyzed１６patients who were bedridden for one week immediately after onset of post-stroke hemiplegia. We used DXA（dual energy X-ray absorptiometry）to determine changes in muscle mass in the lower extremities on both paralyzed and non-paralyzed sides. The first measurement was conducted ３ to ５ days after the onset, and the second measurement was conducted ７ days after the first. Muscle mass in the lower extremities was reduced by approximately ６００g （９％） on the paralyzed side with and by ２００g on the non-paralyzed side （３％） in the Brunnstrom stage≤II group （n＝５）. Although the decrease of muscle mass in the Brunnstrom stage≥III group（n＝１１, relatively slight degree of functional motion impairment）was not significant, a decrease of approximately ３００g （decrease rate ： ５％）was observed on the paralyzed side and approximately １００g （decrease rate ： １．５％）was seen on the non-paralyzed side. Hence, muscle mass declined on both sides, and this occurred regardless of degree of paralysis. The findings suggested that conventional range of motion exercises, functional position maintenance, and postural changes are inadequate to prevent disuse muscle atrophy in post-stroke patients ; thus, it is necessary to develop a new rehabilitation program which adopts different exercises such as trunk motion, even for patients in the acute stage after stoke onset