一位全身性紅斑性狼瘡病患脫離呼吸器之加護經驗

Nursing Care Experienc e of a Patient with Systemic Lupus Erythematosus being Weaned from the Ventilator in an Intensive Care Unit

本文敘述一位36 歲女性病患，因全身性紅斑性狼瘡併發呼吸衰竭，經歷插管治 療後成功脫離呼吸器之加護經驗，護理期間自2016 年11 月26 日至12 月6 日，運 用Gordon 十一項功能性健康評估，藉由直接護理、觀察、會談、身體評估等方式 收集資料，歸納出主要護理問題為低效性呼吸型態、潛在危險性感染、焦慮。於照 護期間，藉由教導強化呼吸肌力量，改善呼吸型態；同時透過組合式照護模式來預 防感染及降低潛在感染合併症的發生；與個案取得信任關係後，降低其焦慮及呼吸 困難的感受，並經跨團隊共同擬定照護計畫，提供個別化的護理措施，獲得最佳身 心適應，期望此照護經驗分享。提供護理人員日後臨床照護此類病患之參考。

 

This article describes the nursing care experience of caring for a 36-year-old female patient with Systemic Lupus Erythematosus. The intubated patient with respiratory failure was successfully weaned from the ventilator in the intensive care unit. The nursing period was from November 26, 2016 to December 26. With the Gordon’s 11 Functional Health Patterns assessment tool, the author collected data through direct patient care, patient observation, patient interview, and medical chart review. The three identified major health problems were an ineffective breathing pattern , potential risk of infection, and anxiety. With increased respiratory muscle strength through specific exercises, the respiratory pattern improved. We implemented Bundle care to prevent infection and reduce the complication rate. The team focused on the patient’s feelings, built a good therapeutic relationship, and reduced her anxiety and difficulty with breathing. With a multidisciplinary care model, we drew up a care plan and provided individual nursing intervention. The patient accommodated herself to the physical activities and mental situation well. The author hopes to share this nursing experience with those who will take care of patients in similar situations in the future.