運用ABCDEF組合式照護一位流感重症病人譫妄之加護經驗

The Nursing Experience of a Patient with Severe Complicated Influenza and Delirium: An Application of ABCDEF Bundle Care

本文描述一位57歲男性，因流感併發重症導致呼吸衰竭使用呼吸器，透過ABCDEF組合式照護改善譫妄之加護經驗，護理期間為2023年4月22日至5月2日，以Gordon十一項健康功能型態評估，運用直接觀察、會談、身體評估及病歷查閱等收集資料，確立個案有一、呼吸道清除功能失效/與流感及痰液蓄積無法有效咳嗽有關，透過執行胸腔物理治療及深呼吸咳嗽等技巧，促進痰液排出以改善肺部浸潤；二、急性混亂/與插管病人使用鎮靜止痛藥物和身處加護病房陌生環境有關，藉由ABCDEF組合式照護改善譫妄，意識清楚並能配合治療；三、焦慮/與不了解病情擔心日後無法工作影響經濟有關，透過觀看衛教影片了解病程進展及預後，能表達正向態度。個案於5/1脫離呼吸器，5/7出院。建議日後針對無窗戶之床位設置模擬燈光條、環繞音響，由電腦自動偵測並模擬窗外光線與聲音變化，改善加護病房內日夜顛倒，降低譫妄發生。期望藉此照護經驗分享，做為未來臨床護理人員照護之參考。

This study examined the nursing experience of caring for a 57-year-old male who developed respiratory failure due to severe influenza complications, subsequently requiring mechanical ventilation. The unfamiliar ICU environment and the use of sedatives and analgesic medications contributed to the onset of delirium. The nursing period was from April 22, 2023, to May 2, 2023. Based on physical assessments, direct observation, care interventions, interviews, and data collection using Gordon’s 11 Functional Health Patterns, the following health problems were identified: ineffective airway clearance related to influenza and accumulated secretions impairing effective coughing, which was managed through chest physiotherapy and deep breathing and coughing techniques to promote secretion clearance and reduce pulmonary infiltration; acute confusion related to sedation, analgesia, and the unfamiliar ICU environment, which was addressed using the ABCDEF bundle, leading to delirium improvement and restored consciousness; and anxiety related to uncertainty about the illness, economic concerns, and future work, which was alleviated via educational videos explaining disease progression and prognosis, consequently helping the patient develop a positive outlook. The patient was successfully weaned off the ventilator on May 1, and discharged on May 7. For ICU patients in windowless rooms, it is recommended to install simulated lighting strips and surround sound systems that mimic outdoor light and sound changes to mitigate day-night reversal and reduce delirium. This care experience serves as a reference for clinical nursing staff managing similar cases in the future.