NURS4604 Group Project: Diabetes Mellitus (Case 10-17)

Personas & Drama Flow Script

1. 人物設定 (Personas)

1. 社區護士 (Community Nurse - CN)

• 性格與態度：專業、有同理心 (Empathetic)、文化敏感度高。
• 溝通技巧：運用 IMB 模型 (Information, Motivation, Behavioral Skills) 及 Collaborative Goal Setting (CGS)。不帶指責語氣，重視長者「面子」。
• 護理重點：將糖尿病管理（如戒口、足部護理）重新包裝成「維持獨立生活能力、可以繼續同朋友打麻雀」的必要條件，藉此打破病人的「宿命論」(Fatalism)。
• a. Assessment (除咗 document 俾咗嘅 assessment)
  • Original:
    • Vital signs: All normal
    • H’stix (when fasting): 3.5 mmol/ L (suggest as mild hypoglycemia)
    • Skin: dry with erythema over both feet and thickened toenails
    • Urine test: ketone -ve
  • Additional:
    • Ask question: Present condition, past medical history, medication adherence + test medication administration
    • Physical: Checks vision (difficulty reading syringe), foot sensation (neuropathy test), hydration status, wound odor/discharge.
    • Psychosocial: Explores Judy’s belief in destiny, mahjong habits, social support and traditional remedies.
    • (Campinha-Bacote's Model): Assesses fatalistic views ("disease is destiny"), social engagement (mahjong), traditional remedy use on diabetes self care (moxibustion or acupuncture use on foot care).
    • Home Environment: Reviews fridge contents (diet), medication storage, wound care supplies, check lighting, bathroom grab bars (fall risks).
• b. Health concept & knowledge to persuade/ improve self-care
  • Use IMB (Information-Motivation-Behavioral Skills) Model and Collaborative Goal Setting (CGS).
  • Frame diabetes management as preserving "Face" and functional independence to enjoy time with grandchildren and mahjong.
  • Hypo/hyperglycemia symptoms and severity.
  • Diabetic Retinopathy (if DM is not controlled well).
  • Educate both client and caregiver that DKA would cause flu-like symptoms, which her present complaint is a possible sign of poor management.
  • Proper insulin technique: Educate on proper insulin technique (suggesting a magnifying aid or pre-filled insulin pens) and timing of Metformin/Repaglinide.
  • Foot care routine.
  • Balanced diet alternatives for mahjong gatherings.
  • Persuasion strategy (reframes “destiny”):
    • → “You can still enjoy mahjong if you take small steps to protect your health.”
    • → "It is your fate to be a respected elder, let's keep your blood sugar stable to fulfill that destiny."
  • Also need to comfort the son.
  • Tertiary Prevention:
    • Emphasize daily foot inspection.
    • Explain the "Sedentary Paradox" of Mahjong (good for cognition, but needs mobility breaks).
    • Suggest substituting high-sugar snacks at the mahjong table with nuts/unsweetened green tea.
• c. Introduce community health resources
  • 綜合家庭服務中心 + 手册
  • Community Nursing Services (CNS) for wound care
  • District Health Centre (DHC - 地區康健中心) for ongoing multidisciplinary support
  • Diabetes HongKong (香港糖尿聯會) and "Meals on Wheels" (送飯服務)
• d. Analyze the data provided to the client
  • Nurse explains risks: poor glycemic control (suspect, as flu-like symptoms appear and flu medication is ineffective), wound infection, hypoglycemia as blood glucose 3.5 mmol/ L (suspect insulin overdose).
  • Explain disease burden: Link DKA admission and foot wound directly to poor glycemic control (HbA1c 9.5-11%).
  • Link her dizzy spells to a fasting glucose of 3.5 mmol/L (hypoglycemia).
  • Links Judy’s lifestyle (mahjong snacks, fatalism) to disease burden.
  • Uses visual aids (charts of HbA1c trends, foot care diagrams).
• e. Any accidents happen during the interview, how to solve
  • Judy feels dizzy mid-assessment → Nurse calmly checks glucose, provides juice/fast-acting carb (juice), reassures son.
  • Judy spills insulin while preparing → Nurse calmly demonstrates correct technique, reassures Judy.
  • Judy struggles with syringe → Nurse calmly supports and educates using behavioral skills without making her "lose face".

2. 鄧婆婆 (Judy Lee, 72 歲 - 病人)

• 性格：固執、有「宿命論」思想（覺得「糖尿病係命水，醫嚟都冇用」）、愛面子。
• 生活習慣：
  • Sedentary Paradox (靜態矛盾)：一星期打三次麻雀。打麻雀對認知有益，但久坐不動兼經常食高糖/高脂小食（如飲茶食點心），導致血糖控制極差。
  • 自我管理極差：HbA1c 9.5-11%，早前因 DKA 入院；不理會左腳的嚴重傷口；未能正確觀看胰島素針筒刻度；經常不按時服藥。
• a. Experience that consolidates her belief
  • “My friend died from diabetes complications, so I think it’s fate.”
  • “I already suffer 10-year DM, i have lived enough.”
  • “My foot doesn’t feel pain, it is ok, and I can still walk. No need to do it every day, so annoying.”
  • “D 藥都差唔多，打多少少都冇野啦，呢十年都係咁過。”
  • Values "Face" & Social Harmony: “出去同 friend 食飯，呢樣唔食嗰樣唔食好唔老禮”
  • The "White Rice Conflict": ‘‘一個星期食得嗰一兩次，想吃得開心D都唔得呀？’’
• b. More content for her unhealthy lifestyle / poor tertiary prevention habits
  • Passive acceptance: Poor foot care, dismisses wound seriousness (ignores greenish discharge).
  • Poor adherence to drug dosage: Partly due to visual impairment reading syringe and misunderstanding dosage.
  • Eating style: Can still keep healthy when at home, but eats very heavily when eating with friends.
• c. Mahjong friends bring her to do what
  • "Sedentary Paradox": Plays mahjong 3 times/week for cognitive health, but lacks mobility breaks.
  • Eats out with mahjong friends: Often indulging in sweet snacks and oily food (飲茶 - Dim Sum). Fear of "losing face" if she refuses to eat.
• d. Any complaints, health burden
  • Complaint of flu-like symptoms a week ago, flu medication given without effect.
  • Complaints of dizziness, thirst, and fatigue.
  • Footcare feels complicated, can’t do it every day.
  • Complaints of Diet limitation.
• e. Any accidents happen during the interview
  • Judy feels dizzy mid-assessment (fasting H'stix 3.5 mmol/L - hypoglycemia).
  • Judy spills insulin while preparing: Struggles to read syringe graduation correctly / forgets insulin dose.
• f. Personality & Relationship between caregivers (need to show these personalities & attitudes when designing the script)
  • Stubborn, fatalistic (“illness is destiny”), sociable with mahjong friends, but resistant to lifestyle changes.
  • Relies on son but sometimes dismisses his concerns, sees him as “nagging.”

3. 明仔 (Caregiver / 兒子)

• 性格：孝順但焦慮 (Anxious)、壓力大、缺乏照顧技巧。
• 處境：需要兼顧工作與照顧母親 (Caregiver stress)。
• 痛點：不懂得如何處理母親的傷口、不知道如何煮健康的糖尿餐、對母親不聽勸告感到既沮喪又憤怒，容易在護士面前與母親發生口角。
• a. Caring problem, worries (can be himself + Judy)
  • Worries about wound infection and hypoglycemia.
  • Notices Judy’s unhealthy habits with mahjong friends (snacking, skipping repaglinide & metformin insulin).
  • Struggling: Judy often goes out to eat unhealthily when he goes to work.
  • Judy keeps complaining she doesn’t like the food he prepares.
  • Worries that Judy is not following drug compliance.
• b. Anything 補充 about his mother's lifestyle + with mahjong friends' lifestyle
  • “She eats cakes with her mahjong friends and skips insulin.”
• c. Any self-situation that affects care
  • Struggles to balance work and caregiving.
  • Struggles to prepare food before and after work, lacks nutritional knowledge.
  • Doesn’t know or lacks confidence to deal with wound care.
• d. Anything want to clarify from Judy's health management & the nurse education
  • Questions about insulin timing and wound care.
  • Any skills to facilitate caring.
  • Any more food choices.
• e. (+/-) How to react to accident
  • When the nurse interprets hypoglycemia, questions the nurse.
  • Feels guilty when the nurse suspects poor DM management (as flu symptoms do not respond to flu medication); also blames the mother for not focusing on management.
  • Panics when Judy feels dizzy.
  • “I’m afraid she’ll get another infection or collapse again.”
• f. Personality & Relationship between caregivers (need to show these personalities & attitudes when designing the script)
  • Caring but anxious, feels burdened, frustrated when Judy ignores advice.
  • Protective, sometimes overbearing, but deeply devoted to his mother.

2. 戲劇意外設計 (Drama Accidents - 扣連 Marking Rubric)

1. 意外一：雪櫃探秘 (The Fridge Discovery)
   • 情境：(Scene 2) 護士檢查雪櫃中的藥物儲存情況時，除咗發現胰島素存放位置不當，還「意外」發現 Judy 偷偷存放的高糖甜點（麻雀朋友送的）。
   • Rubric Fulfillment：展示 Cultural/Dietary Assessment，兒子當場崩潰責怪母親，護士展現 Empathy 並運用 IMB 模型介入，將「限制飲食」轉化為「均衡飲食」。
2. 意外二：低血糖暈眩 (The Hypoglycemia Episode)
   • 情境：(Scene 3) 評估中途，Judy 突然摸住額頭說「好暈、流冷汗」。護士即時篤手指 (H'stix 3.5 mmol/L)。
   • Rubric Fulfillment：考核 Interpretation of Data (辨識低血糖) 及 Intervention (即時給予果汁/快糖)。護士分析原因是 Judy 服用 Metformin/Repaglinide 卻因為打麻雀而 skip meal。
3. 意外三：老花倒瀉藥 (The Insulin Spill)
   • 情境：(Scene 4) 護士要求 Judy 示範抽胰島素，Judy 視力模糊兼手震，看不清刻度，不小心將胰島素滴在桌上。Judy 表現得毫不在乎：「哎呀滴咗少少落枱，D 藥都差唔多，打多少少都冇野啦，呢十年都係咁過。」
   • Rubric Fulfillment：帶出 Disease burden (Diabetic retinopathy/neuropathy 影響日常生活) 及病人的不重視。護士沒有指責，反而教導使用放大鏡或轉用 Pre-filled Insulin Pen (Behavioral skills)。
4. 意外四：無痛的潰瘍 (The Silent Infection)
   • 情境：(Scene 4) 護士檢查左腳趾，一除襪發現大量綠色分泌物伴隨惡臭 (+++ green discharge)，但 Judy 卻說「一啲都唔痛，無事啦」。
   • Rubric Fulfillment：強烈對比。護士解釋高血糖導致神經壞死及傷口難以癒合 (Disease Burden)，並為她清洗傷口。隨後作出 Referrals (轉介 Podiatrist 及 CNS wound care)。

3. 劇情流程圖 (Drama Flowchart)

4. 劇本大綱 (Scene-by-Scene Script Outline - Cantonese)

Scene 1: Introduction & Initial Rapport Building (引子與建立關係)

• 劇情/對白建議：護士抵達 Judy 家中。用友善、關懷的語氣與 Judy 及兒子（明仔）打招呼，建立良好 Rapport。
• 對話重點：護士主動詢問 Judy 出院後狀況，明仔顯得十分緊張（帶出 Caregiver stress 前奏），而 Judy 則表現出不以為然。護士保持專業與耐心 (Professional Attitude)。

Scene 2: Comprehensive Health Assessment (全面健康評估)

【Part A: Subjective Data & History】

• 行動：護士詢問 Judy 過去一星期的徵狀。Judy 抱怨早前有像感冒的症狀 (flu-like symptoms)，食了感冒藥也無效，近兩日更覺得經常口渴、疲倦及頭暈。

【Part B: Cultural Assessment (Integrated)】

• Social activities：Judy 提到每星期打三次麻雀，而且經常與雀友「飲茶食點心」，因為「唔食好唔俾面，會冇面子」。
• Caregiver stress and understanding：明仔發脾氣投訴：「姑娘你睇佢呀，我返工做到死，佢就掛住同人食糖水，點湊呀！」展現照顧者的壓力與對糖尿病飲食認知的缺乏。
• Readiness for self-management：Judy 表現出強烈的宿命論 (Fatalism)：「病就係命水啦，我都七十幾，食少舊又唔會長生不老」。護士暫不反駁，溫和記錄。

【Part C: Physical Assessment (Objective Data)】

• Vital sign：護士量度血壓、脈搏、血氧等（全屬正常）。
• Hstix：【Accident 2 - 低血糖暈眩】 進行中途 Judy 突然標冷汗、頭暈。護士冷靜篤手指，發現空腹血糖只有 3.5 mmol/L。
• Foot assessment：【Accident 4 - 無痛的潰瘍】 護士檢查雙腳，發現皮膚乾燥、腳甲變厚，左腳大拇趾清創後有大量綠色惡臭分泌物 (greenish discharge +++)。Judy 卻表示完全不痛。展示神經病變 (Neuropathy) 的嚴重性。

【Part D: Home Environment Assessment】

• Fall prevention：護士觀察單位內的燈光及洗手間扶手，提醒明仔小心地上的雜物會增加跌倒風險（作一般常規評估，不安排跌倒意外）。
• Medication storage：【Accident 1 - 雪櫃探秘 - 藥物】 護士請明仔打開雪櫃檢查藥物儲存，發現胰島素存放位置混亂及溫度不當。
• Food storage：【Accident 1 - 雪櫃探秘 - 食物】 同時在雪櫃內發現 Judy 偷偷存放的高糖甜點 (西餅)。

Scene 3: Interpretation, Analysis, and Explanation of Disease Burden (詮釋、分析及解釋疾病負擔)

• Interpretation of Data：護士向兩母子解釋，Judy 的暈眩與冷汗並非感冒，而是 低血糖 (Hypoglycemia)。原因是食了降糖藥 (Repaglinide) 但因為打麻雀而 skip meal (無食正餐)。
• Explaining Disease Burden & Health Determinants：護士將 HbA1c 9.5-11%、早前的 DKA 入院，以及現在的「無痛嚴重腳潰瘍」串連。解釋因為長期高血糖導致神經受損與微血管阻塞，傷口無法癒合，若不處理可能需要截肢。
• Setting Goals (SMART Goals - Collaborative)：
  • 運用 IMB 與 CGS：護士明白打麻雀對防止腦退化有益 (Sedentary Paradox)，不要求完全戒絕。
  • Goal 1：未來一星期，打麻雀時自備無糖餅乾，每兩圈起身飲水伸展。
  • Goal 2：明仔協助 Judy 每日定時檢查腳趾，及確保留低一半健康晚餐給婆婆。

Scene 4: Education on DM Control (糖尿病控制教育)

• Nutrition：教導明仔如何為婆婆準備均衡飲食，將「嚴厲戒口」轉化為「選擇更健康的烹調方式與替代食品」，減輕母子衝突。
• Hypoglycemia Management：護士教導如何辨識低血糖症狀，並指導在家中準備「急救糖/果汁包」。
• Medication Management：【Accident 3 - 老花倒瀉藥】 護士請 Judy 示範準備 Prototype HM 胰島素。Judy 視力模糊兼手震，不小心將胰島素滴在桌上。然而 Judy 表現得毫不在乎：「哎呀滴咗少少落枱，D 藥都差唔多，打多少少都冇野啦，呢十年都係咁過。」展示她對病情的輕視。護士沒有責怪，反而順勢引入教育：建議轉用預先裝滿的 Insulin Pen 減少出錯，並糾正她的用藥觀念。
• Foot Care & Wound Management：護士當場一邊示範 Wound Dressing (即場洗傷口)，一邊教育切勿光腳走路、應穿著合適防滑鞋，並每日用鏡檢查腳底。

Scene 5: Health Advice for Community Dwelling & Professional Attitude (社區生活建議與專業態度)

• Hydration：建議婆婆在床邊及麻雀枱旁邊放置水杯，確保充足水分排出體內過多糖分 (預防 DKA)。
• Fall Prevention：建議明仔清理走廊雜物及地墊，並安裝夜燈，防止婆婆夜晚去廁所跌倒。
• Emergency Plan：寫下一張大字報，列明低血糖處理方法與緊急求助電話，貼在雪櫃門上。護士全過程展現出高度的 Professional Attitude (不斥責、有同理心、專注解決問題)。

Scene 6: Interdisciplinary Approach & Community Resources & Referrals (跨專科合作與社區資源轉介)

• 護士說明單靠他們母子兩人是很辛苦的，介紹跨專科團隊的幫助以減輕照護壓力：
  • CNS (社區護士)：轉介上門為 Judy 左腳洗傷口，監察感染情況。
  • Podiatrist (足病診療師)：轉介深入處理變厚腳甲及足部潰瘍問題。
  • Dietitian (營養師)：協助明仔度身訂造符合 Judy 口味且控制血糖的餐單。
  • Elderly Centre / Social Worker 及 DHC (地區康健中心)：轉介社工跟進明仔的 Caregiver stress，並讓 Judy 在日間中心參加健康的社交活動。
  • Family Doctor：定期跟進整體病情。

Scene 7: Plan for Subsequent Visits & Closing (後續探訪計劃與總結)

• Medication Management closing：護士與二人確認已經學會使用新的 Insulin Pen 及低血糖急救。
• Caregiver stress and understanding：護士再次稱讚明仔的孝心，安撫他的焦慮，並肯定 Judy 願意改變的決心。
• Plan for next visit：護士表示因為傷口感染嚴重 (green discharge)，計劃在一週後再次上門 (Subsequent visit)，跟進洗傷口進度、足部狀況以及檢查血糖機記錄。護士愉快道別。