一位敗血症併發急性腎損傷個案成功脫離呼吸器之護理經驗

A Nursing Experience of Weaning the Ventilator for a Patient with Acute Kidney Injury caused by Sepsis

本文敘述一位82歲男性個案，因敗血症併發急性腎損傷而初次接受透析，進行 呼吸器脫離之護理經驗。護理期間為2014/3/27-2014/5/2，筆者藉由筆談、觀察、身體評估等方式收集資料，運用Gordon十一項健康功能型態進行護理評估，確立個案的健康問題為呼吸器戒斷反應功能失常、呼吸道清除功能失效、皮膚完整性受損、焦慮等。經與醫師、呼吸治療師、復健師、營養師與個案共同擬訂及參與呼吸照護計畫，藉由胸腔物理治療維持呼吸道通暢，每二小時翻身並檢查受壓部位、無菌技術換藥預防感染使傷口癒合，提供透析及呼吸器脫離相關護理指導，協助解決透析及因呼吸器依賴導致身心不良反應降低個案的焦慮，提供個別性的照護，讓個案能面對透析及透析治療帶來生活上的改變，增進其自我照護能力。期望藉此照護經驗分享，應用於護理實務並做為日後臨床照護之參考。

The article described the author's nursing experience about a patient (a 82-year-old-male) with acute kidney injury caused by sepsis accepting first hemodialysis and weaning ventilator successfully. The author applied Gordon's 11 Functional Health Patterns to collect data through observation, interview and communications for integral assessment during the period of caring from March 27, 2014 to May 2, 2014. Four main problems included dysfunctional ventilator weaning response, ineffective airway clearance, impairment of skin integrity, and anxiety were noted. In addition, the medical group worked together to create respiratory caring program including chest physiotherapy, change position every 2 hours and aseptic techniques for wound care to prevent infection and by which the patient could complete the training and withdraw from mechanical ventilator. Besides, the author also provide individual nursing care to help the patient solve anxiety and face to the physical function change then accept long-term hemodialysis in the future and finally enhance his self-care ability. This article provide the medical teams good reference while caring similar patients.