運用治療性遊戲協助一位學齡期肺炎病童促進肺部擴張之成效

The Effectiveness of Applying Therapeutic Play to Help a School-Age Child with Pneumonia for Lung Expansion

肺炎是兒童期常見的呼吸系統疾病，常出現「呼吸道清除功能失效」的護理問題。在本個案研究中，病童因為肺葉右中葉浸潤，加上多為無效性咳嗽，無法有效地排出痰液，故本文運用治療性遊戲來促進肺部擴張。考量學齡期兒童的發展特色及病童喜愛球類運動與繪畫後，結合指導性、生理健康促進性與情緒宣洩性之治療性遊戲種類，設計闖關遊戲，第一關為人體器官掛圖衛教(利用「細菌卡通圖片」貼在肺葉上進行肺炎疾病衛教)、第二關為吹足球比賽(自製足球場、可移動式球門及保麗龍足球)，第三關為「水彩吹畫」，反覆練習腹式呼吸和噘嘴吐氣，並訂定行為契約（每天玩吹足球至少一次，每次10-15分鐘，執行後蓋章集滿集點卡後可換發獎狀），以強化深呼吸運動技巧，並由案母返家後繼續執行。藉由回覆示教評值發現病童已能正確運用腹式呼吸與執行噘嘴吐氣，從原始每30分鐘3-4次的無效性咳嗽轉變為每30分鐘1-2次的有效性咳嗽，故達成促進肺部擴張之護理成效。本個案研究之優點在秉持「無創傷性照護」之理念，邀請家屬參與此過程，同時訂定適合且具體的行為契約，以協助病童肺部擴張的持續性，讓呼吸道清除功能儘早復原。

Pneumonia is a common childhood respiratory disease. “Ineffective airway clearance” is the major nursing problem. In this case study, due to the right middle lobe lung infiltration, this hospitalized child experienced frequently ineffective cough and did not able to expel sputum smoothly; therefore, we designed a series of therapeutic play to increase lung expansion of this child. For development theories of school-age child and the favorite sports game and drawing of the child consideration, we combined instructional, physiologically enhancing, and emotional play to design a three-level game named “Breaking through the Barricade”. First, the initial game was health education by flipchart of lung (using cartoon pictures of bacteria sticking onto the flipchart to illustrate the cause and effects of pneumonia). The second game was “football game by mouth” (goaling by blowing the hand-made tiny soccer). The third game was “creative blowing paint”. We encouraged the child to practice diaphragmatic breathing and pout expelling repeatedly, then to set behavior contract with him (blowing football game every day at least 10-15 minutes to collect points for a special award). These games were designed to strengthen the deep breathing skills, which continue to be performed by his mother and him after returning home. In midst of the evaluation of this therapeutic play by return demonstrations, we found the patient had a huge progress on performing diaphragmatic breathing and pursed lips breathing. In the beginning, the child coughed 3-4 times every 30 minutes ineffectively; but after the practice, he coughed effectively 1-2 times every 30 minutes. The effectiveness of applying therapeutic play to promote lung expansion has been approved. This case study applies the principles of “atraumatic care”, and invites the family to join this process. Moreover, an appropriate and specific behavior contract also contributed to promote persistent lung expansion and effect recovering from ineffective airway clearance.