一位肌無力危象患者之護理經驗

Nursing Experience with a Patient Suffering a Myasthenia Crisis

本文探討肌無力危象病患之護理經驗，筆者以羅氏適應模式為評估工具，藉訪談、觀察及身體評估進行資料收集，確立健康問題有：呼吸道清除功能失效、身體活動功能障礙、便秘及焦慮。照護期間採計劃性呼吸器脫離訓練、訂定肢體復健計劃、穴道按摩、教導放鬆技巧、提供相關資訊及鼓勵家屬陪伴減輕焦慮。最終使病患脫離呼吸器，成功移除氣切套管，達到最佳健康狀態。期望此照護經驗能與同儕分享，並作為日後照護此類個案之參考。

The purpose of this article is to illustrate the author’s nursing experience with a patient suffering a myasthenia crisis. The author collected information by interview, observation and physical assessment utilizing the Roy Adaptation Model. The results indicated that the patient had potential problems related to ineffective airway clearance, impaired physical mobility, constipation and anxiety. During the nursing period, the author established a ventilator weaning program and rehabilitative activity plan, initiated acupressure, taught relaxation techniques, offered relevant information and encouraged relatives to help alleviate the patient’s level of anxiety. We hope the experience gained will be helpful to our fellow nurses in their clinical practice.