照顧一位冠狀動脈心臟病合併肺水腫病人之加護護理經驗

Caring for a coronary heart disease patient with pulmonary edema in the intensive care unit

本文描述一位73歲女性，因冠狀動脈心臟病合併肺水腫出現呼吸困難，進行氣管內管插管後入住加護病房的護理經驗。護理期間為2011/04/13至2011/04/23，筆者藉由會談、溝通、身體評估及肢體語言等方式蒐集個案資料，依生理、心理、社會及發展、靈性的四大層面，以全人的方式來分析並確立個案健康問題，評估後有氣體交換功能障礙、潛在危險性感染及焦慮等健康問題。護理過程中嚴密監測生命徵象，給予氧氣，維持呼吸道通暢，增加心肌氧氣供應，改善呼吸情形和血中含氧濃度，並採適當擺位維持舒適，減少耗氧量，採取預防感染之相關護理，運用傾聽，藉由言語、手勢鼓勵引導個案內心感受表達，並適時提供訊息，使其了解周遭環境和儀器的運作方式，建立護病信任關係降低焦慮等護理措施，改善個案的心肺功能及減低因疾病所引起的焦慮。藉此個案護理經驗，期望本篇報告能作為往後護理人員在照顧相關個案及執行臨床照護上之參考。

This article describes a 73-year-old woman with pulmonary edema due to coronary heart disease, difficulty in breathing, endotracheal intubation ICU stay after nursing experience. Care for the period 2011/04/13 to 2011/04/23, by the author talks, communication, body language and other physical assessment and to collect information on the case, according to the physical, psychological, social and development, the four spiritual level in full one way to analyze and establish the case of health problems, the assessment of gas exchange dysfunction, anxiety, risk of infection and other health problems. Nursing care was implemented to closely monitor vital signs, provide support oxygen, maintain airway patency, supplement the myocardial oxygen supply, improve breathing and blood oxygen concentrations, help the patient maintain an appropriate and comfortable position, reduce oxygen consumption and prevent infection. The patient was encouraged to express her feelings through listening, vocalization and gestures. Information was provided to orient the patient to the environment and show her how to operate the instrument. Establishing trust in the nurse-patient relationship can help reduce patient anxiety. Nurses should refer such cases for appropriate care.