一位失償性肝硬化合併頑固性腹水患者之護理經驗

本文旨在描述一位失償性肝硬化患者，因頑固性腹水而反覆入院之護理經驗。護理期間自2017年1月21日至2017年2月7日。照護期間以Gordon十一項功能性健康型態為評估工具，發現個案因肝硬化併門脈高壓及血中白蛋白減少而有「體液容積過多」的護理問題；因頑固性腹水，對疾病預後不佳及支持系統不良而有「焦慮」的護理問題；且因肝功能下降導致血中的氨濃度增加而出現「急性混亂」的護理問題。照護期間，藉由定時評估呼吸型態、床頭搖高15~30度以增加肺部的擴張，並教導限水、限鈉的飲食原則，以及依醫囑行腹腔放液術和補充蛋白質，以減少體液的聚積及維持呼吸順暢；其次，以傾聽、開放式談話鼓勵個案表達內心的想法和感受，當個案情緒低落時，予以治療性觸摸，表達關心、同理心，做為個案和親人之間的溝通橋樑，讓親人了解個案無力感。除外，增強個案對疾病及居家自我照護的認知，以減輕個案的焦慮；在個案出現急性混亂期間，定時評估其意識狀態、維持安全環境、依醫囑給予乳果糖酸化結腸及給予低蛋白飲食。對於慢性病患者，家人的支持更顯得重要，個案返家後為獨居生活，建議針對此類獨居患者，應給予長期照護資源協助，使其能得到良好的照護。盼藉此護理經驗能提供護理人員作為日後照顧類似病人之參考。 This article describes the nursing experience of a female patient with decompensated cirrhosis and repeated admission due to refractory ascites. The period of nursing care was from January 21, 2017, to February 7, 2017. During nursing care, the patient's health conditions were assessed according to Gordon's 11 functional health patterns, which revealed that her complications consisted of three parts: fluid overload due to liver cirrhosis with portal hypertension and decreased albumin levels; anxiety resulting from refractory ascites, poor prognosis and an inadequate support system; and acute confusion related to high plasma ammonia concentration, which was caused by liver function deterioration. Numerous adjustments were made to help the patient during nursing care. Physically, her breathing patterns were evaluated periodically, and the head of her bed was raised 15°–30° to improve pulmonary dilation. She was educated on the principles of a water-and salt-restricted diet, and paracentesis and protein supplementation were conducted per medical orders to prevent body fluid accumulation and to maintain smooth breathing. Psychologically, she was encouraged to express emotions and thoughts through caring and open discussions, during which the therapeutic touch was used when she felt depressed. Throughout the course of care, by offering both sympathy and empathy, the author served as a bridge of communication between the patient and the family, enabling her family to understand her sense of helplessness. Additionally, her knowledge about the disease and self-care measures at home were enhanced to ameliorate her anxiety. During the period when symptoms of acute confusion occurred, her conscious state was periodically evaluated, and the safety of her environment was ensured. Furthermore, lactulose as prescribed by the physicians was administered to facilitate acidification of the colon. The patient was also provided a low-protein diet. For patients with chronic diseases, the support of family members is even more important. After returning home, the patient is a solitary life. It is recommended that long-term care resources should be provided for such solitary patients so that they can be well cared for. The findings from this nursing experience can serve as a reference for other nursing professionals when caring for similar patients in the future.