一位支氣管擴張症病患急性呼吸衰竭護理經驗

Nursing Experience of Caring for a Patient with Bronchiectasis

本文探討一位支氣管擴張症病患因疾病需要使用高濃度氧氣治療，因急性呼吸衰竭症狀，瀕臨插上氣管內管來維持呼吸系統功能入加護病房照護過程。筆者自2003年6月5日至6月10日護理期間，運用Gordon十一項功能性健康護理評估，藉直接會談、傾聽、觀察方法收集資料作整體性評估，發現個案主要護理問題為呼吸道清除功能失效、活動無耐力、睡眠型態紊亂、焦慮。因有感一旦插上氣管內管為侵入性醫療行為，致病患身、心、靈諸多影響，也增加醫療成本耗費，故護理過程透過信任感及良好治療性關係建立，專業知識及技巧運用，讓個案免於插上氣管內管，改善個案危急生命問題及疾病帶來之困擾，使其獲得更多疾病資訊，進而改善生活品質。

The paper was aiming at describing the nursing experience of caring for a patient with bronchietasis in intensive care unit. The nursing care duration extended from June 5 to 10, in 2003. The author used clinical observation,interview and physical assessment guided by the Gorden 11 functional health status to identify the patient's major health problems. There were four major nursing diagnosis which were ineffective airway clearance, activity intolerance, sleep pattern disturbance and anxity. Then the nurse designed many nursing interventions and during the caring period we gained good therapeutic relationship between the nurse and the patient,to help this patient get through the acute stage. Through the nursing process the patient was relieved of the disease discomfort and his quality of life was promoted.