一位呼吸衰竭插管病患急性疼痛之護理經驗

Nursing Experience for a Patient with Endotracheal Tube Placement

本文探討一位呼吸衰竭插管病患急性疼痛之護理經驗。照護期間為2008年8月22日至25日，運用Gordon十一項健康功能進行整體性評估，並經由實際參與個案照護過程中，透過觀察、身體評估、會談等方式收集主、客觀資料，確立個案健康問題為：一、氣體交換障礙；二、急性疼痛；三、口腔黏膜受損。在護理過程中，針對此三項主要護理問題提供病患個別性之護理措施：教導個案腹式呼吸、有效的咳嗽方法並適時會診營養師評估營養狀況進而改善呼吸困難及氣體交換功能障礙情形，再輔以穴位按摩及轉移注意力等多元性護理措施減緩個案插管之急性疼痛，使用非黏著性之敷料及兩小時評估氣管內管受壓部位，改善氣管內管留置導致之口腔黏膜受損等，並在醫療團隊共同努力下，促使病患病情獲得緩解終能順利轉出加護病房。期望藉由此篇個案報告之撰寫，提供加護病房護理人員在插管病患照護上之參考。

The purpose of this article reports a nursing experience for a patient with respiratory failure and acute pain secondary to the placement of an endotracheal tube. The nursing period was from August 22 to August 25, 2008. Data were collected through patient observation, physical examination, and patient interview. An assessment was done through the use of Gordon's 11 items health functional status. The three identified major health problems were (1) impaired blood gas exchange; (2) acute pain; and (3) impaired integrity of the endotracheal membrane. Individualized nursing interventions were implemented, such as instruction of abdominal breathing, effective coughing, and nutritional counseling, to improve the patient's respiratory status and disturbance in blood gas exchange. Acupressure and distraction of the patient's attention to pain helped the pain relief. The application of non-adhesive dressing and periodical pressure check of the endotracheal tube improved the healing of the injured membrane. With the medical team's efforts, the patient's condition stabilized and the patient was transferred out of the ICU. This article may be used as a reference for ICU nurses taking care of patients with endotracheal tubes.