照顧一位罹患Guillian-Barre症候群病患之護理經驗

Nursing experience of caring for a patient with Guillain-Barre syndrome

本篇個案報告主要在描述協助一位罹患 Guillian-Barre 症候群導致行走功能障礙之 14 歲青少女，接受雙重血漿過濾置換術治療之護理經驗。照護期間自 100 年 4 月18 日至 100 年 4 月 27 日，筆者經由身體評估、會談、觀察、傾聽等技巧收集資料，並採用 Gordon 十一項健康功能評估，加以分析整理，發現個案主要有身體活動功能障礙、焦慮、潛在危險性感染等護理問題。護理過程中示教漸進式的關節復健運動及肌力訓練，進而協助個案能使用輔助器自行步行，使患者四肢肌力達 4 分以上；建立良好的護病關係，鼓勵個案表達內心的感受，並運用音樂特有的旋律及節奏轉移注意力及教導鬆弛技巧，以減輕其內心的焦慮感，緩和疾病引起身、心之壓力；教導正確照顧股靜脈雙腔導管、無感染情形發生。受限於雙重血漿過濾置換術治療的時間一天約 2 小時，在徵得病患的同意下，筆者利用非治療時間，親自到病房追蹤護理指導成效。透過本個案照護經驗分享，期盼血液透析護理人員在照護 Guillian-Barre 症候群病患時，除了短暫雙重過濾血漿置換術治療時間外，更能兼具潛在身、心健康問題之協助，讓血液透析護理更具整體完善。

This article describes nursing experience with a 14-year old girl handicapped by Guillain-Barre syndrome that received double filtration plasmapheresis therapy between April 18 and April 27, 2011. The author collected data through physical examinations, interviews, observation and listening to the patient. Gordon,s eleven functional health patterns were used to carry out the nursing assessment. The author found that the patient had some nursing problems including physical dysfunction, anxiety and high risk of infection. During the nursing process, progressive joint rehabilitation exercises and strength training were taught to the patient. The patient was eventually able to walk on her own using mobility aids and limb muscle strength increased to over 4 points. A good relationship was established with the patient and the patient encouraged to express her feelings. Musical melodies and rhythm was used to divert the patient's attention and teach relaxation techniques that helped to alleviate anxiety. The correct care of the femoral vein double lumen catheter was taught and no infection occurred. As double filtration plasmapheresis therapy took approximately 2 hours each day, the author secured the patient’s consent to visit her ward outside of treatment sessions to track the effectiveness of nursing education. The author hopes that this nursing experience will provide nursing staff with a useful reference during double filtration plasmapheresis treatment in the future.