照顧一位Guillain-Barré 症候群個案之護理經驗

The Nursing Experience of Caring a Guillain-Barre Syndrome (GBS)

本篇為照護一位Guillain-Barre 症候群（Guillain-Barre Syndrome, GBS）個案之護理經驗，護理期間為2011年3月18日到3月26日，運用Gordon十一項健康功能型態進行護理評估，因發病後出現全身四肢無力及需留置氣管內管，透過觀察臉部表情及肢體動作，運用單字卡及自製注音符號拼字表板收集資料，歸納出健康問題為呼吸道清除功能失效、身體活動功能障礙、不確定感。透過護理計畫與護理措施，清除痰液恢復正常呼吸音、配合長期的呼吸復健訓練，於住院期間即將損傷程度和活動限制能力納入護理計畫，進而讓個案獲得較佳的健康生活品質，在疾病認知上也因缺乏足夠資訊，造成心理上擔心、害怕等不確定感，自製注音符號拼字表板引導個案表達內心感受，增加自我控制感以適應疾病過程，給予口述GBS疾病相關資料，強化對疾病的了解，減輕心中的不確定感，方能儘早積極配合後續治療與護理活動計劃，使病情獲得改善，期本文能為日後相似個案照護之參考。

This case study is about the nursing experiences of a Guillain-Barre Syndrome (GBS) patient. The nursing period was from March 18 to 26 of 2012. The Gordon’s functional health assessment guide was used to assess nursing problems. Limited by general weakness and placement of the endotracheal tube ventilator, information was collected through direct patient care, observation of the body language and use of a phonetic alphabet board. The nursing problems included ineffective airway clearance, physical activity dysfunction, and uncertainty. Nursing care plans and measures aimed to maintain the patency of the airway for the prevention of mucus accumulation, combined with the long term respiratory rehabilitated activities to enhance quality of life. Worry, fear, and uncertainty were caused by the lack of disease information. Homemade phonetic alphabet spelling board was provided to express his feelings and communicate and increase the sense of self-control. Disease-related health education was provided verbally in order to reduce uncertainty. The patient was encouraged to participate the rehabilitation programs and actively cooperate with the treatment plan so that the condition can improve. The nursing experience provides references for nursing colleagues who care similar patients in the future.