照顧一位裘馨式肌肉萎縮症併呼吸衰竭病人之加護經驗

The Nursing Experience for Duchenne Muscular Dystrophy with Respiratory Failure in the Intensive Care Unit

本文描述一位罹患裘馨式肌肉萎縮症的個案因呼吸衰竭而入住加護病房的護理過程。照護期間由2013 年2 月17 日到2 月28 日，運用身體評估、會談與觀察等方式進行資料收集，並以Gordon 十一項健康功能型態評估為指引，發現個案出現的健康問題包括：低效性呼吸型態/ 與呼吸道炎症反應、神經肌肉導致肺擴張減少有關；身體活動功能障礙/ 與肌肉功能受損、關節攣縮有關；焦慮/ 與進入陌生環境有關等三項健康問題。護理過程中藉由與個案建立良好護病關係，針對其健康問題共同擬定合適的護理計畫，包括教導個案噘嘴式呼吸法、有效的呼吸咳嗽技巧，順利脫離呼吸器；並協助肢體關節運動，保持活動功能以預防肢體攣縮與變形加劇；在心理方面，透過筆述鼓勵個案說出內心感受，以克服住院期間所造成的恐懼感，以降低焦慮程度；提供個別性、連續性之照護措施，不僅協助個案瞭解並參與照護計畫，期望藉此提升臨床護理實務及照護經驗應用。

This paper describes the nursing process of caring an ICU patient suffering from Duchenne muscular dystrophy with complication of respiratory failure. The nursing period was from February 17, 2013 to February 28, 2013. The researcher used physical evaluation, interview, and observation to collect the data and Gordon 11 healthy function evaluation as the guidance. The results revealed that the health problems include: ineffective breathing pattern related to the disease –caused respiratory muscle weakness; physical activity dysfunction / muscle dysfunction related to joint contractors; anxiety / psychological pressure related to unfamiliar environment. During the nursing process, by establishing the good patient-nurse relationship with the case patient, the researcher developed the appropriate nursing plans based on the health problems to provide the patient with individual and continuous nursing measures to help understand and refer to the nursing care plan. After teaching the case patient how to use the pout breathing, effective coughing skills, the patient was removed from the ventilator smoothly. Moreover, the researcher assisted the patient in limb and joint movement to keep moving functionality, and prevent the worsening of limb contraction and deformation. In the psychological aspect, by writing, the patient is encouraged to express inner feelings to overcome the sense of fear from being hospitalized. Therefore, the degree of anxiety is thus reduced to enhance clinical nursing practice and care experience application.