運用早期活動計劃協助一位呼服器依賴病人脫離呼吸器

Nursing experience of early mobilization in mechanically ventilated patient

本文為描述一位長期依賴呼吸器的老年人其脫離呼吸器之照護經驗。護理期間為 2015 年 9月6日至 2015 年 10月5 日，依照Gordon十一項健康功能評估及觀察、訪談、身體評估及參閱病歷等方式進行資料收集，確立個案的主要健康問題有呼吸器戒斷反應功能失常、營養不均衡、身體活動功能障礙、焦慮等健康問題。透過護理活動及運用跨圖隊合作，早期且積極介入漸進式康復活動計畫：攝取適當熱量以提升身體肌耐力及活動度：在脫離呼吸器訓練過程中，改善（圖案的支氣管痘彎，增進舒適度：心理方面，以傾聽、關懷及陪伴方式，協助釐清焦慮原因，提供適當的護理指導幫助個案了解脫離呼吸器之照護計畫，進而增加（圖案的控制感，緩解焦慮的情緒並增加信心，以維持最佳的呼吸功能並順離脫離呼吸器，進而擺脫長期臥床之種種限制，提高生活品質。期望藉經驗分享，讓護理人員重視脫離呼吸器說訓練個案的早期復健活動計畫灰心理調適，做為日後照護之參考。

The author described the care experience of a person who relied on respirators for a long time. The caring period was from September 6, 2015 to October 5, 2015. Data were collected by means of observation, interview, physical assessment, medical records and Gordon 11 item Functional Health Pattern Assessment, and the main health problems of this patient including dysfunctional ventilator weaning response, malnutrition, impaired physical mobility, and anxiety were diagnosed. Medical cross-team members made rehabilitation programs including early mobility and appropriate calories intake to increase the ’patients body muscle endurance and activity. During the process of the ventilator weaning training, we solved bronchospasm to make the patient comfortable and helped to clarify the causes of anxiety by lestining, caring and company to maintain the best respiratory function and weaning from ventilator successfully, then get rid of the various restrictions on long-term bed rest to improve the quality of life. With this sharing experience, we hope that nurses should pay attention to the early rehabilitation program and psychological adjustment of the patients with weaning from ventilator as a reference.