照顧一位急性肺水腫病患成功脫離呼吸器之護理

The Nursing Care of a Patient with Acute Pulmonary Edema Weaning Successfully from Ventilator

本文為一位75歲女性，因慢性心臟衰竭導致急性肺水腫，引發意識不清、呼吸衰竭等症狀，在接受氣管內管置入及呼吸器輔助後，病情逐漸穩定，成功脫離呼吸器。在生命受到疾病威脅時，除了肉體折磨，也會產生極大的精神壓力。照護期間為90年2月28日至90年3月7日，以歐倫護理系統進行整體評估，確立此病患有氣體交換障礙、營養狀況改變／少於身體所需、自我照顧能力缺失、焦慮等健康問題。藉由提供完全代償性護理措施，協助病患渡過疾病急性期。當病患脫離呼吸器後，運用部份代償性護理措施，並以教育系統評估病患對疾病認知程度，給予適當衛教。配合與疾病照護相關的護理措施，促進病患發揮最佳自我照顧能力，達到維持生活品質之目的。The researcher reported a 75-year-old female who suffered from the respiratory failure and conscious disturbance due to chronic heart failure with an episode of acute pulmonary edema and therefore, received endotracheal intubation and mechanical ventilation. After recovering gradually, she was weaned from ventilator successfully. When the life-threatening attack happened, this patient confronted not only physiological but also psychological stress. She was filled with enormous anxiety during the disease course. Performing the systemic evaluation with Orem nursing system during the caring period, from 28th February to 7th March in 2001, we found several problems, such as impaired gas exchange, alteration of nutrition status, lack of self-care ability, and anxiety. We took the complete compensatory nursing measures to help this patient get through the acute stage. After weaning successfully from ventilator, partial compensatory nursing measures were taken. With support and education systems, we evaluated her understanding of the respiratory failure and provided her proper nursing information to improve the self-care ability and to maintain life quality.