運用羅氏適應模式照顧一位心衰竭致呼吸困難病人之護理經驗

本文是照護一位心臟衰竭合併呼吸困難及周邊水腫病人之護理經驗。護理期間為2021年3月18日至2021年4月1日，運用羅氏適應模式的第一層次及第二層次評估方式，收集主客觀資料並且分析內外刺激源，確立體液容積過量、活動無耐力、知識不足等三個主要護理問題。住院期間病人接受經皮冠狀動脈介入性治療，改善缺血性心臟病及呼吸困難狀況。護理人員協調呼吸治療師及復健人員共同介入，配合呼吸肌力訓練計畫、心臟復健運動計畫以及護理衛教，提供支持、照護和正向回饋，使個案能面對疾病的治療、減緩體液容積過量及活動無耐力情形，最後經由反覆衛教幫助個案在生理、自我概念、角色功能、相互依賴等模式中獲得調適，並逐漸恢復四肢肌力及提升自我照顧能力。

This article outlines the nursing care provided to a patient diagnosed with heart failure experiencing dyspnea, spanning from March 18th to April 1st, 2021. Employing Roy's theory, assessments were conducted across physiological-physical, self-concept, role functional, and interdependence modes to evaluate changes and stimuli. Three nursing diagnoses were identified: fluid volume excess, activity intolerance, and knowledge deficit. During hospitalization, percutaneous coronary intervention was utilized to address ischemic heart disease and alleviate dyspnea. Collaborating with physiatrists and respiratory therapists, cardiac rehabilitation programs were implemented. These programs included muscle strengthening exercises for respiration, nursing interventions, and mental support, ultimately aiding in dyspnea relief and facilitating cardiac rehabilitation efforts. By the conclusion of the care period, the patient demonstrated reductions in fluid volume excess and activity intolerance, exhibited positive coping responses, and improved self-care knowledge and abilities.