- 期刊
一位初產婦產後併發深部靜脈血栓與肺栓塞之重症照護經驗
Intensive Care Experience for a Primipara Complicated with Deep Vein Thrombosis and Pulmonary Embolism
摘要
本文探討一位初產婦產後兩週發生下肢靜脈血栓症合併肺栓塞之加護照護經驗。照護期間自2020年2月5日至2月7日，筆者運用Gordon十一項功能健康型態進行評估，藉由身體評估、觀察、會談等收集資料，照護過程確認個案有靜脈血栓導致灌流不足之氣體交換障礙及無效性周邊組織灌流、初產婦產後罹患重大疾病，面臨親子分離及無法親餵導致之焦慮等健康問題。針對健康問題密切監測生命徵象，尤其是呼吸型態及氧合變化，避免氧合不足導致低血氧危害狀況；每2－4小時評估肢體末梢血循變化（如：蒼白、脈搏及溫度改變），並詢問有無感覺異常、麻木、疼痛不適等，並監測有無藥物副作用發生、指導個案自我照護注意事項，以減緩疼痛不適並預防復發機率；建立良好護病關係傾聽並陪伴，幫助產後階段面臨危急疾病之調適，透過視訊及母乳擠出再利用以降低親子分離及無法親餵之焦慮。期望藉此照護經驗提供護理人員對於相關疾病過程健康問題及其臨床照護之參考。
並列摘要
This article describes the nursing experience of a primipara complicated with deep vein thrombosis and pulmonary embolism within 2 weeks after delivery. The period of nursing was from February 05 to February 07, 2020. Gorden's functional healthy assessment was used, and supplemented by physical assessment, observation, interview and chart review to collect relevant information. The healthy problems were confirmed as following: an insufficiency in gas exchange and ineffective peripheral tissue perfusion were related to venous thromboembolism; and the experience of anxiety was related to parent-child separation because the patient was unable to undertake breastfeeding. According to the problems, these nursing intervention were made: closely monitoring the peripheral circulation such as paleness, pulsation, poikilothermic, paresthesia, numb, or pain; evaluating the side effects of antithrombotic agents; provision of self-care education; building a nurse-patient relationship through listening and companionship; reducing the feeling of anxiety using video contact and assisting with breast milk expression. We hope that the nursing experience in this case can be used as a reference for clinical nursing staff.