照護一位抗磷脂質症候群個案之護理經驗

A Nursing Experience of a Patient with Anti-Phospholipid Syndrome

李佩津(Pei-Chun Lee) ； 楊芝齡(Chi-Ling Yang) ； 廖淑貞(Shu-Chen Liao)

《志為護理-慈濟護理雜誌》 15卷4期 (2016/08) Pp. 85-95

摘要

本文描述一位因罹患罕見疾病抗磷脂質症候群，導致右側偏癱的成年男性之護理經驗。照顧期間為2014年5月23日到6月13日，筆者運用Gordon十一項健康功能型態為評估工具，以查閱病歷、會談、身體評估及直接護理等方式收集資料；發現個案有：自我照顧能力缺失、潛在危險性跌倒、情境性低自尊及家庭運作過程改變等四個健康問題，護理過程中，透過醫療團隊與家屬的陪伴及同事的鼓勵，共同建立個案的自信心，提供案妻疾病資訊，減少其焦慮，並使用輪流照顧方式，維持家庭運作。筆者期望藉由此次照護經驗的分享，提供臨床護理人員參酌，以提升此類個案的照護品質。

關鍵字

抗磷脂質症候群 ； 自我照顧能力缺失 ； 情境性低自尊

並列摘要

This article described the nursing experience of an adult male with right hemiparesis that was caused by anti-phospholipid syndrome. The nursing period lasted from May 23^(th) to Jun. 13^(th), 2014. The author applied Gordon's 11 function health patterns as an assessment tool and collected data through medical records, conversation, physical assessment, and direct care. The health problems identified included self-care deficit, risk of falls, situational low self-esteem, and altered family process. To address theses health issues, during the nursing process, the author implemented the following nursing interventions: establish the patient's confidence through the company of the family members and the medical team; relief the anxiety of the patient's wife by providing relevant disease information, and maintain family integrity. The author hopes that this nursing experience could serve as a reference for clinical nurses to improve overall quality of care when tending to patients with similar conditions.

並列關鍵字

anti-phospholipid syndrome ； self-care deficit ； situational low self-esteem