照顧一位急性肺水腫放置氣管內管個案之護理經驗

Nursing Experience of a Endotracheal Intubated Patient with Acute Pulmonary Edema

本篇描述一位急性肺水腫合併急性呼吸衰竭的老年個案於加護病房之照護經驗。自2008年12月5日至2008年12月19日的照護期間以觀察、非語言溝通與家屬直接會談方式進行收集資料，確立其主要照護問題為：體液容積過量、活動無耐力、焦慮等問題。針對個案護理問題給予專業知識及適切之照護措施改善體液容積過量外，更依照個案之個別性及獨特性，提供擴胸運動及四肢肌耐力訓練，以增加胸部肌肉及四肢肌肉耐力，進而達到脫離呼吸器並降低其焦慮感。筆者感於加護病房此類似個案眾多，希望藉由此照護經驗作為往後護理人員照護之臨床參考。

This article presented a nursing experience of an elderly patient in an intensive care unit (ICU) who had acute pulmonary edema, complicated with acute respiratory failure. The duration of nursing care was from December 5th to 19th , during which observation, nonlanguage communication and family interview were conducted as data collection methods. The following major health issues of the patient were established: volume overload, exercise intolerance, and anxiety. In addition to providing professional knowledge and optimal care measures to treat volume overload, the author specifically organized exercises and trainings to improve muscle endurance of chest wall and limbs, attempting to wean the patient from ventilator and reduced the patient’s anxiety. Due to increasing numbers of such patients in ICU, this article provided specific nursing experiences as a reference for nursing staffs in future clinical practice.