照護一位肝硬化合併食道靜脈曲張出血患者之護理經驗

本文是探討一位因肝硬化合併食道靜脈曲張破裂出血患者之照護經驗，照護期間自2005年4月30日至2005年5月7日，筆者運用羅氏適應模式，實際的互動、觀察、會談並以身體評估技巧收集資料，經由分析確立個案的健康問題：體液容積缺失、體液容積過量、低效性呼吸型態、潛在危險性損傷及恐懼等。提供適當的護理措施，如緩解個案因出血及合併症造成的生理上不適，並降低心理上對出血的恐懼，進一步提供疾病和出血徵象的觀察及預防衛教，增進其預防發生再次食道靜脈破裂出血之自我照護能力。

關鍵字

肝硬化；食道靜脈曲張出血

並列摘要

This article discuss about the nursing experience of caring a patient who suffers liver cirrhosis and esophageal varicose vein bleeding. From April 30th 2005 to May 7th 2005, the writer used Roy's adaptation model, practical interaction, observation, interview and physical assessment skill to collect information. By analyzing the information, the writer indicated the health problems of the case are: deficient fluid volume, excess fluid volume, ineffective breathing pattern, risk for injury and fear. By giving good care such as relieving physical discomfort or fear caused by bleeding and providing ways to observe the signs and prevention of disease and bleeding, help the patient to promote the ability of self-caring for preventing esophageal varicose vein bleeding again.