照顧一位猛爆性肝衰竭患者的護理經驗

Experience of a Patient with Fulminant Hepatic Failure

本篇個案報告描述一位猛爆性肝衰竭病患，於民國九十四年三月十四日到民國九十四年三月二十三日共十天在加護病房期間的護理過程，運用觀察、會談技巧及直接護理收集資料，並以Gordon十一項功能性健康型態進行整體性評估，個案在加護病房期間有呼吸道清除功能失效、體液容積過量、睡眠型態紊亂、潛在危險性皮膚完整性受損、焦慮及身體心像紊亂六項主要護理問題，針對個案的護理問題給予適當之護理措施如協助物理治療、教導低鈉飲食的攝取等，以利個案的健康問題獲得改善。此護理經驗可提供護理人員在照護猛爆性肝衰竭病患時，對病患可能會發生的健康問題有一概念，並能計劃適當之護理措施，以提升病患生理及心理的舒適。

This case report describes the process of nursing a patient with fulminant hepatic failure. Nursing care was provided in the intensive care unit from March 14th to 23rd 2005. Clinical observation, interviews and direct care were used as data. Based on Gordon's 11-item functional health assessment, the patient's health problems were identified as the following: ineffective airway clearance, excess fluid volume, disturbed sleep patterns, risk of impaired skin integrity, anxiety and disturbed body image. In order to improve the client's health, It is important for nurses to provide appropriate nursing intervention, such as chest care and education about keeping a low salt diet. This report provides nurses with a whole picture of caring for a patient with hepatic failure and of planning the appropriate nursing intervention to promote the patient’s physical and psychological comfort.