一位煙霧吸入導致肺損傷病患之護理經驗

Nursing Experience of Caring a Patient with Inhalation Injury

煙霧吸入的病患，因為肺部受損引發氣體交換障礙，焦慮等護理問題會隨之而來。本文於台北某醫學中心加護單位收案，護理期間自92年12月5日至12月14日止。經由觀察、會談、身體評估及運用Gordon十一項健康功能型態評估進行資料收集，確認病患有氣體交換障礙、焦慮、活動無耐力/如廁等主要護理問題。藉由與醫療團隊合作與討論、主動關懷、提供相關訊息等護理措施，協助個案解決問題。化學性煙霧吸入所造成的損傷是漸進性，筆者希望藉此個案報告的護理經驗，作為照護此類患者的參考，不僅解決生理問題，更注意到心理層面上的照護，以達到整體性護理的目的。

This article described the nursing experience of a patient with inhalation injury inducing acute lung injury, impaired gas exchange, and anxiety. The patient’s condition was assessed through observation, interview, and physical examination using the Gordon functional health assessment guide and medical chart review. The three major nursing health problems being identified included impaired gas exchange, anxiety, and activity intolerance/toileting. The nursing intervention, through teamwork and cooperation, active caring, effective discussion, and provision of related information, resolved this patient’s problems. The damages produced by the chemical inhalation injury could be progressive. This experience provided nurses with a reference to understand the physiological progression of a patient and to assess patient’s physiological and psychological status in order to achieve the goal of holistic care.