一位行冠狀動脈繞道手術患者之加護經驗

An Intensive Care Nursing Experience of a Coronary Artery Bypass Surgery Patient

衛福部統計心臟疾病為十大死因的第二位，本文個案因急性心肌梗塞行冠狀動脈繞道手術後之加護經驗。於2014年4月21日至5月01日護理期間，運用Gordon十一項健康功能型態為架構，以身體評估、會談、病歷查閱等方式，確立有心輸出量減少、急性疼痛、高危險性感染、急性混亂等健康問題。過程中密切監測生命徵象、觀察膚色、溫度及尿量；傾聽感受、教導放鬆與適當傷口支托，及調整止痛劑；執行無菌技術換藥、提供適當熱量促進傷口；運用降低噪音及亮度措施促進睡眠品質，病情穩定後轉出加護中心，期望藉此照護經驗分享，能作為臨床護理人員照護此類個案時的參考。

According to statistics published by the Ministry of Health and Welfare, cardiac diseases is the second leading cause of death nationwide. The article described a nursing experience of a patient who received coronary artery bypass graft surgery, and the nursing period was from Apr. 21st to May 1st, 2014. By collecting data through physical assessment, interviews, and medical records and using Gordon’s functional health patterns as an assessment framework, the patient was confirmed to have decreased cardiac output, acute pain, highrisk for infection, and acute confusion. The nursing interventions included listening, teaching relaxation skills, providing proper wound support, and adjusting analgesics, implementing aseptic dressing technique, providing adequate calories, and minimizing voice and brightness to enhance sleep quality, and close monitoring of vital signs, skin color, temperature, and urine output during the process. The patient was transferred out of ICU once stabilized. We wish that this nursing experience could serve as a reference for other clinical nurses when facing similar cases.