照顧一位原發性腸系膜靜脈硬化症併發結腸壞死的護理經驗

Nursing Management of a Patient with Idiopathic Mesenteric Phlebosclerosis Combined with Colonic Ischemia

10.6692/KJN.202112_38(3).0007

陳碧雪(Pi-Hsueh Chen)；司淑英(Shu-Ying Sz)；黃憶如(Yi-Ju Huang)；陳家鳳(Chia-Fong Chen)

原發性腸系膜靜脈硬化症 ； 結腸壞死 ； 結腸次全切除 ； 暫時性終端迴腸造口 ； 山槴子 ； Idiopathic Mesenteric Phlebosclerosis ； colon necrosis ； subtotal colectomy ； End ileostomy ； Gardenia fruit

高雄護理雜誌

38卷3期（2021 / 12 / 01）

75 - 86

繁體中文

本文係探討一位原發性腸系膜靜脈硬化症併發結腸壞死個案之護理過程。照護期間自2016年1月7日至1月18日，筆者經由身體評估、會談、溝通、傾聽、引導等方式收集主客觀資料，運用Gordon十一項健康評估工具進行整體性護理評估，並加以歸納分析。個案健康問題為造口高排出量導致體液容積缺失、營養少於身體所需及出院後造口護理帶來的強烈焦慮。透過傾聽、陪伴、主動關懷，與個案建立信任關係，發現個案長期服用含山槴子成分中藥，依文獻佐證與罹患罕見原發性腸系膜靜脈硬化症具高度相關性，及時地讓個案了解此潛在風險，以降低剩餘直腸再次壞死機率。

This article discusses the nursing process of a Patient with Idiopathic Mesenteric Phlebosclerosis Combined with Colonic Ischemia. During the period of care from January 7th to January 18th, 2016, data were collected using physical assessment, interviews, communication, listening, guidance, and Gordon's 11 health assessment tools for holistic nursing assessments. The health problem in this case was loss of body fluid volume due to high stoma discharge, fluid volume deficit and anxiety. The patient was found to be a long-term user of traditional Chinese medicine containing Hawthorn, which is highly correlated with rare primary mesenteric venous sclerosis. Timely intervention to help the patient understand this potential risk was actioned so as to reduce the chance of re-necrosis of the remaining rectum.