一位瀰漫性血管內凝血併無望感個案之急診護理經驗

An Emergency Nursing Case Experience of Disseminated Intravascular Coagulation and Hopelessness

本文敘述一位急性膽囊炎合併瀰漫性血管內凝血並出現無望感之個案，於急診之照護經驗。個案於2014/2/9至2014/2/10急診照護期間，經臨床數據、理學檢查及身體評估，亦將個案病史列入考量，診斷為急性膽囊炎引發之瀰漫性血管內凝血；此外，個案缺乏支持系統而產生無望感，進而影響治療意願及其生理疾病的改善情形，筆者認為除生理問題外，心理層次的問題亦不容忽視，故以此個案照護經驗進行探討。筆者以Gordon十一項健康功能型態評估、觀察、會談及病史資料收集，確立個案有潛在危險性傷害（出血）、現存性感染及無望感等健康問題。在急診照護期間，提供個別性症狀護理與衛教、心理支持、評估心理困擾程度、主動關懷及陪伴等照護措施，使個案未出現嚴重出血、感染惡化及自殺等情形發生。本文分享醫護團隊的介入措施，如協助聯絡家屬、與家屬進行溝通及安排後續照顧，然而，因受限於急診照護期間短暫，因此建議在個案轉至加護病房時，對此情形加強交班，亦可在交班評估單新增心理及自殺危險性評估項目，並於個案出院後採電話訪問持續追蹤，使個案得到連續照護，此案例之分享更加凸顯出醫護團隊連續性照護的重要性。

This paper describes a case of acute cholecystitis complicated with disseminated intravascular coagulation (DIC) and the experience in caring this case in emergency department (ED) who showed subsequent signs of hopelessness. The diagnosis of acute cholecystitis complicated with DIC was made during emergency care from 2014/2/9 to 2014/2/10 using the clinical data, physical examination and physical assessment of this case. Past medical history was also taken into consideration. In addition, hopelessness due to lacking support system affected the patient's willingness to treat the diseases and physiological condition. I believe that besides physical problems, psychological level issues should not be ignored. Hence, the caring experience of this case was discussed in this paper. I used Gordon eleven functional health patterns assessment to observe, communicate and collect the past history, thereyby confirming that this case had existing health problems such as potentially dangerous injuries (bleeding), infection and hopelessness. Individualized symptom nursing with health education, psychological support, assessment of the degree of psychological distress, proactive care with companionship, and other precautious measures were provided during ED caring. As a result, this case did not show severe bleeding, infection, deterioration or suicide incident. This article shared the experience of medical team's interventions, such as assistance to contact as well as communicate with the families, and arrangement for further medical care. However, due to the limitation of the short stay in emergency care, in cases like these transferred to the intensive care unit, I will recommend thorough shift change between nurses, addition of the plans for reevaluation of the psychological factors and new suicidal risk project, and regular telephone follow-up after discharge in order to have continuous care. The sharing of this case highlights the importance of the continuity of care of a medical team.