- 期刊
一位肝硬化併發腹水及肝性胸水病人之加護護理經驗
Intensive Nursing for a Patient with liver cirrhosis Complicated with Ascites and Hepatic Hydrothorax
摘要
本文敘述一位肝硬化病人併發腹水合併肝性胸水導致呼吸衰竭入住加護病房之護理經驗。護理期間為2011年5月1日至2011年5月14日，筆者運用Gordon十一項功能健康型態進行整體性評估，經由直接照護、紙筆溝通、觀察等方式收集及分析資料，護理過程中確立個案有氣體交換障礙、體液容積過量、現存性感染、焦慮等健康問題。針對個案之健康問題：維持有效呼吸型態與呼吸道通暢，達到足夠氣體交換，進行呼吸訓練；密切監測輸入出量，減緩體液容積過量之不適；監測生命徵象、密切評估並提供完整管路照護以降低感染合併症的發生；主動傾聽、同感心支持，建立良好護病關係之下，鼓勵個案表達內心感受，並提供疾病照護訊息與因應措施，讓個案建立信心，勇於面對疾病變化的衝擊，成功緩解個案之焦慮。藉此加護經驗提供護理人員在照護類似病人之參考。
並列摘要
We aimed to report a 35-year-old man with cirrhosis complicated with ascites and hepatic hydrothorax and further discuss nursing care with respect to respiratory failure related to massive hydrothorax. Nursing care was provided in the intensive care unit from 1th to 14th May 2011. We collected data regarding physical examinations, direct nursing care, communication and clinical observation based on Gordon's functional health patterns. The problems of gas exchange impairment, fluid overload, infection and anxiety were identified. According to individualized nursing care plan, we maintained effective breathing patterns and airway to achieve adequate gas exchange for successful weaning from the ventilator, closely monitored input and output to improve discomfort due to fluid overload, provided intrusive line care to reduce chance of infection. We established a good nurse-patient relationship from attentive listening and empathetic support. We assisted the patient in resolving the associated clinical problems, encouraged him to express his feelings and provided disease-associated care information. Moreover, we enhanced the patient's confidence in dealing with the impact of the disease. Accordingly, the patient had the ability to cope with stress and reduce anxiety. This nursing care provides references for nursing colleagues to care patients with similar problems in the future.
被引用紀錄
延伸閱讀
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