一位罹患左下肢深部靜脈栓塞病人之急診照護經驗

A Nursing Experience of a Patient in Emergency Suffering from Left Lower Leg Deep Vein Thrombosis

蘇慧芳(Hui-Fang Su) ； 梁孟婷(Meng-Ting Liang) ； 葉惠玲(Hui-Ling Yeh)

《志為護理-慈濟護理雜誌》 20卷1期 (2021/02) Pp. 113-121

摘要

本文是一位24歲男性，因左下肢腫脹及疼痛延伸至大腿和足背造成行走困難，急診就醫並診斷左下肢深部靜脈栓塞之個案。急診照護期間為2018年7月10日14點44分至7月11日14點26分，藉由觀察、直接照護、身體評估、訪談及病歷查閱等方式收集資料，並運用生理、心理、社會及靈性評估，確認主要健康問題有周邊組織灌流失效、知識缺失、不遵從。照護期間持續評估下肢腫脹變化，執行Heparin醫囑，密切監測APTT指數變化；此外，藉由詳細說明抗擬血藥物作用及治療處置，提升個案疾病認知；並透過衛教戒菸之重要性，協助個案正視疾病願意逐漸減少抽菸量，進而改變生活型態。期望藉由此分享照護經驗，提供急診照護之參考。

關鍵字

深部靜脈栓塞 ； 周邊組織灌流失效 ； 知識缺失 ； 不遵從 ； 急診

並列摘要

This case report described the nursing experience of a 24-year-old man who has difficulty walking due to swelling and pain in the left lower extremity that extends to the thigh and the back of the foot. The patient went to the hospital for emergency treatment and was diagnosed with deep vein thrombosis in the left lower extremity. The nursing period commenced on July 10, 2018 (2:44 pm) until July 11, 2018 (2:26 pm). Data were collected through observation, direct care, physical assessment, interviews, and medical records. The author used physical, psychological, social, and spiritual assessments. The patient's major health problems were ineffective peripheral tissue perfusion, knowledge deficit, and noncompliance. Continuous assessment of changes in the lower extremity, implementation of heparin orders, and closed monitoring of APTT data during the care period were done. In addition, the author explained the effects of anticoagulant drugs and treatment plans. Thus, the patient's knowledge of the disease was improved. Through health education on the importance of smoking cessation to help successfully treat the disease, the patient was willing to gradually reduce the amount of smoking and change lifestyle. It is hoped that a reference for emergency care will be provided through this sharing of care experience.

並列關鍵字

deep vein thrombosis ； emergency ； ineffective peripheral tissue perfusion ； knowledge deficit ； noncompliance

參考文獻

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