一位脊髓損傷合併深部靜脈栓塞患者之護理經驗

A Nursing Experience of a Spinal Cord Injury Patient with Deep Vein Thrombosis

本文探討一位因高處跌落導致頸椎損傷併發深部靜脈栓塞個案之護理經驗。護理期間自2013年8月10日至2013年8月31日，筆者運用Gordon十一項健康功能評估為架構，藉由觀察、會談、身體評估及查閱病歷等方式收集資料，確立個案主要問題依序排列為周邊組織灌流失效、身體活動功能障礙及焦慮；照護過程中，藉主動關懷及建立良好的治療性人際關係，教導促進患部血液回流、減輕疼痛腫脹方法、主動及被動關節活動、穿著彈性襪，並提供適當輔具、疾病相關資訊和衛教手冊等措施，適時給予正向回饋及家庭成員支持，以避免肺栓塞等合併症的發生，並減輕其焦慮感，期望藉此經驗提供臨床護理人員照護此類個案之參考。

This article described a nursing experience of a cervical spinal cord injury patient caused by a fall from a height with a complication of deep vein thrombosis. The nursing period was from August 10, 2013 to August 31, 2013. According to Gordon's 11 Functional Health Patterns Assessment frameworks, the author used observation, client interview, physical assessment and medical records to collect information. The main problems of the patient were ineffective tissue perfusion (peripheral), impaired physical mobility and anxiety respectively. To prevent complications such as pulmonary embolism and to alleviate patient's anxiety, our nursing interventions included establishing a good working relationship with the patient through active care; instructing patient in the skills of increasing venous return, pain and swelling relief, and educating him or her active and passive range of motion, elastic stockings wearing, and proper use of assistive devices; providing disease-related information and handout forms of patient instructions; and positive reinforcement and family support. We hope this article can provide useful information on clinical nursing practice.