照護一位慢性腎衰竭合併體液容積過量患者的護理經驗

Caring for a Chronic Failure Patient with Body Fluid Overload

沈玲純(Ling-Chun Shen) ； 丘周萍(Chou-Ping Chiou)

《臺灣腎臟護理學會雜誌》 2卷1期 (2003/03) Pp. 40-48

摘要

慢性腎衰竭常見的合併症包括：呼吸、心血管系統，血液、消化、肌肉骨骼、神經、內分泌、免疫系統，以及體液電解質不平衡等問題。慢性腎衰竭，因腎功能衰退，影響體液及電解質排除，常會導致體液容積過量的問題，進而造成心臟衰竭並引起肺水腫，另外也會導致週邊組織水腫。而水腫常會帶來腫脹、沈重和不舒適成。因為水腫本身不會造成立即的危險，因此臨床醫護人員常忽略此問題。但是週邊組織水腫卻可能會導致病人行動不便，甚至造成潛在性皮膚完整性受損或感染的發生。本文是針對一位慢性腎衰竭合併體液容積過量患者的護理經驗，根據個案出現的臨床症狀，運用Gordon十一項健康功能評估方式，針對病人最急迫的護理問題－體液容積過量及潛在危險性皮膚完整性受損，根據文獻查證提供適當的護理措施，並在護理過程中提供適切的護理指導，使個案對疾病有正確的認知，以協助其度過疾病療程及瞭解未來自我照護方式。

關鍵字

慢性腎衰竭 ； 體液容積過量 ； 皮膚完整性受損

並列摘要

The complications of chronic renal failure frequently lead to electrolyte imbalance and dysfunction of many different systems including respiratory, hematological, gastrointestinal, musculoskeletal, neurological, endocrine, cardiovascular and immune system. Body fluid overload caused by electrolyte imbalance may lead to heart failure, pulmonary edema and peripheral edema. Edema is often accompanied by swelling, heaviness and discomfort; these complaints often are ignored by the clinical nurse since the patient is not in immediate danger. However, peripheral edema may cause disability and impaired skin integrity, and even infection. This article focuses on the nursing experience of a patient who suffered from chronic renal failure combined with fluid overload. The clinical symptoms were assessed using Gordon's functional health patterns assessment. Proper nursing interventions were provided based on emergency and references. In order to help the patient endure dialysis treatment and improve self-care ablities for the future, the nursing process included providing patient education including basic information of the disease process.

並列關鍵字

chronic failure ； body fluid overload ； impaired skin integrity