反覆次發的自生性氣胸併發神智急性混亂的老人照護：案例報告

An Experience Taking Care of An Elderly Man with Recurrent Secondary Sponta neous Pneumothorax and Acute Confusion: A case report

本文描述一位反覆次發的自生性氣胸併急性混亂譫妄老人之照護。治療期間，個案持續出現自生性氣胸併皮下氣腫與張力性氣胸等呼吸困難與低血氧症狀。為預防反覆次發的自生性氣胸之發作，個案接受8 次的肋膜沾粘術與經2 次胸腔內視鏡氣泡切除手術。住院期間為2011 年3 月30 至8 月6 日，護理期間為2011 年3 月31 日至6 月21 日，我們收集了加護病房藉由身體評估、觀察、會談及整合醫療團隊合作等資料：運用羅氏適應模式進行整體性評估，確立包含低效性呼吸型態、急性混亂、營養少於身體所需、高危險性感染、睡眠紊亂、活動無耐力、家庭運作功能改變等護理照護問題；並運用按摩、觸摸放鬆技巧與集中照護，安排安全與舒適的環境，提升急性混亂期之睡眠品質；在清醒期適時提供現實認知與心理支持，教導胸腔復健運動並定時鼓勵使用呼吸訓練器等等措施，期待個案早日康復。進而利用陪伴、同理性及個別會談，以提供完整的疾病資訊，讓個案獲得精神上與心理的支持。雖然治療期間個案仍遭受反覆氣胸與皮下氣腫的發作，而無法順利出院，經由個別化的護理措施與社會資源之運用；順利強化個案對疾病的了解，並促成家庭成員共同面對、共同突破經濟困境，進而強化親子、親人之互動。我們深信此案例的分享，可做為相關護理人員照護此類疾病的參考。

We reported a case of recurrent secondary spontaneous pneumonthrax (S. S. P) with repetitive delirium. The patient was a 73 year-old man, suffering from episodes of breathing difficulty, hypoxemia and anxiety, and even developing spontaneous subcutaneous emphysema. He received eight pleurodesis therapies to prevent recurrence of SSP and two transthoracic endoscopic surgeries to remove the collapsed ineffective alveolus. The complete nursing care was done by a targeted team, including physical assessment, interview, and consisted of medical physicians, a nutritional consultant, and social workers. Roy’s adaptation model was applied to assess and disclose the health problems, including ineffective breathing style, acute confusion, inadequate nutrition, high risk of infection, sleep disturbance, activity intolerance, caregiver role strain and altered family processes. Subsequently, massage and touch relaxation techniques were performed, and a safe and comfortable environment was arranged to improve sleep quality in the acute confusion stage. Provision of cognitive reality therapy was also offered. In addition, he was directed to perform pulmonary rehabilitation exercises, and encouraged to inhale a spirometer hour by hour. He was given sufficient listening, attention, repetitive individualized interviews, sincere care, and instruction in adequate health information for respiratory care. After repeated admission and discharge several times, the patient and family then understood the necessity of a strengthened illness cognition. The family organized nursing for individualized care and learned how to utilize the social resources to face their problems. We, therefore, believe a comprehensive health-care management and service care really help in the care of patients with recurrent SSP.