照護一位多處肋骨骨折手術後個案入住加護病房之護理經驗

Nursing Experience of Caring for a Patient with Multiple rib Fractures Admitted to the Intensive care unit Postoperatively

本文探討一位65歲男性因車禍外傷導致右胸3~8肋骨骨折、右側輕微氣血胸及右側肩胛骨骨折個案，因接受經胸腔鏡肋骨骨折開放性復位手術、右上肺鍥狀切除手術後入住加護病房之照護經驗。筆者自2020年9月18日至9月21日藉由直接照護觀察、身體評估、溝通及查閱病歷，運用Gordon十一項功能性健康型態評估進行資料收集，確認個案主要健康問題有:急性疼痛、知識缺失與肋骨手術後復健、傷口照護有關、焦慮擔心疾病預後及後續治療。筆者與個案及家屬建立治療性關係後，了解個案的需求及擔憂的事情，密切觀察個案術後傷口疼痛反應，配合止痛藥物給予，教導以非藥物使用方式如轉移注意力、深呼吸、肌肉放鬆按摩及製作安心抱枕以緩解疼痛，知識缺失與手術後復健、傷口照護方面，予個案說明使用誘發性肺量計行呼吸訓練的目的、使用方法、練習次數及注意事項，並說明翻身活動注意胸管避免拉扯，傷口換藥時傷口周圍有無紅腫熱痛及分泌物產生，對於焦慮擔心疾病預後及後續治療，經由傾聽主動關心鼓勵及陪伴，引導說出心裡感受讓個案情緒抒發，每天由醫療團隊向個案及家屬說明目前病況及後續治療方向，增加個案參與感建立治療信心，希望藉此分享經驗做為在臨床護理類似個案之參考，以達到更完善的護理品質。

We examined the care experience of a 65-year-old man with fractures in the 3rd–8th ribs on the right side, mild right hemopneumothorax, and a right scapular fracture sustained from a road traffic accident; he was admitted to the intensive care unit after undergoing thoracoscopic open-reduction surgery of the rib fractures and right upper lung wedge resection. From September 18 to 21, 2020, we observed the direct care experience, physical evaluation, communication, and reviewing of medical records. Gordon’s 11 functional health patterns were evaluated for data collection, and the chief complaints of the patient were confirmed to be acute pain, lack of knowledge and rehabilitation after rib surgery, poor wound care, and anxiety and worry regarding the disease prognosis and subsequent treatment. After we discussed the treatment strategies with the patient and his family, the patient’s needs and worries were understood, and postoperative wound pain response was closely observed. Non-pharmacological methods, such as distraction, deep breathing, muscle relaxation massage, and bolsters, were used to alleviate pain in combination with analgesics. Regarding the lack of knowledge and postoperative rehabilitation and wound care, the patient was informed of the objective, usage method, practice frequency, and precautions for carrying out respiration training using an incentive spirometer. The patient was instructed to pay attention to the chest tube during body-turning to avoid pulling and to pay attention to swelling, warm sensation, pain, and secretion in the wound during a dressing change. As for anxiety and worry regarding the disease prognosis and subsequent treatment, active listening, care, and companionship were used to guide the patient in revealing his thoughts and release his emotions. Every day, the medical team informed the patient and his family of his current condition and subsequent treatment directions to increase patient participation and build treatment confidence. These findings could serve as a basis for clinical care of similar cases with improved quality.