泌尿器の手術を受けた幼児・学童の苦痛の表出と対処および親の関わり

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[要旨]本研究の目的は，泌尿器の手術を受けた幼児・学童の苦痛表出と対処，および親の子どもへの関わりを明らかにすることである。幼児４名，学童２名とその親６名に術後１病日から退院日まで参加観察を行い，質的帰納的に分析した。子どもの苦痛には，尿道などの創部痛とカテーテルの刺激，排尿時痛などの身体的な苦痛と，オムツや床上排泄する事への心理的な苦痛など多様な苦痛があり，短期間に苦痛の性質が変化するため子どもは苦痛を捉えにくく，苦痛緩和の有効な対処も取りにくいものであった。子どもは苦痛が強いときには『周囲の関わりを拒否し，苦痛緩和につながる表出と対処が困難な状態』であったが，苦痛が落ち着くと『苦痛が軽減する・回復につながる対処を取ることができる状態』になり有効な対処をとることができていた。親はいつもの子どもと比較して苦痛を把握しており，子どもの羞恥心や恐怖心を認識しながらあらゆる方法を駆使して子どもの苦痛軽減を図っていた。子どもの苦痛が強い状況では，親の関わりの選択肢が少なく疲弊しており，親子のやり取りでは苦痛が緩和されず，さらに増強するという悪循環に陥っていた。子どもの苦痛が落ち着くと，回復の促進や子どもの覚悟を支えるなど関わりの幅が広がっており，子どもが主体的に望めるようなやり取りがされていた。以上より，手術内容や発達段階から子どもの苦痛を予測し，泌尿器ゆえの苦痛表出の困難さを配慮すること，親を心理的に支えて子どもへの関わりの資源を増やすことが重要と示唆された。

[SUMMARY] This study aimed to clarify how preschool- and school-aged children who had undergone urological surgery express and cope with distress and how their parents engaged with them. We performed participant observation of four preschool age children, two school age children, and their six parents from postoperative day one until discharge. We then analyzed the data collected using qualitative inductive analysis. The children’s distress levels varied and included physical distress, such as pain in the urethra or other surgical site, irritation from the catheter, pain with urination, and psychological distress concerning wearing a diaper or using a bedpan. As the nature of their distress changed frequently, the children had difficulty understanding the distress and thus struggled to use effective coping methods. When their distress intensified, the children “refused the intervention of others, and had difficulty with expressions and coping to alleviate distress.” However, when their distress subsided, they were “able to use coping methods that reduce or eliminate distress” to effectively cope. The parents understood that their child's distress was out of the ordinary for them and used every method available to try and reduce it, while bearing in mind the child’s feelings of shame and fear. When the child’s distress intensified, there was little that the parents could do, which led to feelings of exhaustion. At such times, interactions between parents and their children did not alleviate the distress, but instead exacerbated it, creating a vicious cycle. As the child’s distress subsided, the scope of the parent’s involvement expanded to include assisting with recovery and supporting the child’s resolve. Notably, parent-child interactions allowed the child to take the lead. These results suggest the importance of predicting distress among pediatric patients based on the surgical procedure and their developmental stage and taking into account the difficulty of expressing distress arising from the urinary organs, as well as assisting parents by providing psychological support and additional resources for engaging with their child.