一位腸缺血術後合併靜脈血栓病人的照護經驗

A Nursing Care Experience a Young Intestinal Ischemia Patient Complicated with Postoperative Venous Thrombosis

本文描述一位腸缺血個案術後合併靜脈血栓之護理經驗。個案僅23歲即小腸切除且發生併發症，引發身心困擾。護理期間為2013年4月20日至5月11日，筆者於個案住院期間，運用觀察、會談、身體檢查、病歷查閱等方式收集資料，運用Gordon十一項健康功能型態來評估個案的健康問題，發現有急性疼痛、焦慮、組織灌流改變：心肺、周邊、潛在危險性損傷。在護理過程中，運用適當的護理措施，包括：傾聽需求並表達感受，教導分散注意力、放鬆技巧減輕疼痛；評估及監測呼吸型態和下肢血循變化，提供預防栓子游離照顧措施，預防深部靜脈血栓惡化，提供資訊使焦慮解除，給予服用抗凝血劑之衛教指導等等，使個案能以正向的態度接受治療，及了解未來自我照顧注意事項，終能順利出院。

This article describes a nursing experience of a patient diagnosed with intestinal ischemia complicated with postoperative venous thrombosis. The patient, age 23, underwent small bowel resection, while the postoperative complication resulted in physical and mental distress. The nursing period lasted from April 20 to May 11, 2013. Data were collected through observation, interview, physical examination and chart review. Gordon’s eleven functional health patterns were applied to identify the patient’s health and nursing problems, and they were acute pain, anxiety, altered cardiopulmonary and peripheral tissue perfusion, and potential risk of injury. In addition to prescribed medicine, the author applied appropriate nursing measures: listening to patient’s needs, assisting the patient to express feelings and emotions, teaching distraction and relaxation techniques to relieve pain, asserting and monitoring breathing type and lower limb blood flow changes, providing preventive care measures to prevent thrombosis and the deterioration of deep venous thrombosis, offering information to alleviate anxiety, health care education on the use of daily intake of anticoagulants. The aforementioned strategies facilitated a positive attitude in the patient to face treatment and a understanding in future self-care strategy, and eventually helped the patient to be successfully discharged. (Tzu Chi Nursing Journal, 2015; 14:3, 83-92)