縱膈腔炎術後併發呼吸衰竭病人脫離呼吸器之護理經驗

Nursing Care Experience of Weaning Ventilator for a Postoperative Mediastinitis Patient with Respiration Failure

本文為協助一位口腔深度感染造成食道破裂並導致縱膈腔炎，術後併發呼吸衰竭病人，入住呼吸照護中心，成功脫離呼吸器之護理經驗。於2012年9月20日至10月5日照護期間，筆者運用Gordon 11項健康功能型態評估，採直接觀察與病人及其家屬會談之技巧，進行整體性評估，確立其健康問題有呼吸道清除功能失效、活動無耐力、營養少於身體所需及焦慮等。照護期間經由主動關懷、傾聽、非語言溝通及陪伴與病人建立良好互動關係，依個別性提供合適的護理措施，攝取足夠熱量需求，並指導其肺部復健運動，增進肌肉耐力，播放喜愛的音樂，提升病人的安全舒適感，透過醫療團隊的合作，順利成功脫離呼吸器。筆者希望藉由此次照護經驗的分享，提供臨床護理人員照護之參考。

This article describes the nursing experience with a postoperative respiratory failure patient at respiratory care center. She suffered from rupture of esophagus leading to mediastinitis after a dental procedure. The duration of nursing care was from September 20th to October 5th, 2012. Gordon's 11 functional Health Pattern Assessment tool was utilized in conjunction with direct observation and interview skills on an individual basis to evaluate the patients globally, as well as to establish the patient s health problems such as ineffective airway clearance, activity intolerance, malnutrition, and anxiety. A good nurse-patient relationship was established by actively caring, listening, nonverbal communication and company. Appropriate nursing interventions were implemented, including adequate calorie intake, instructing pulmonary rehabilitation to strengthen respiratory muscle and providing favorite music to promote patient's sense of security and comfort. This patient was successfully liberated from ventilator via a multidisciplinary approach. The objective of this case report was to share the nursing experience with clinical nursing staff caring for respiratory failure patient undergoing weaning from mechanical ventilation.