協助一位頸椎脊髓完全損傷患者術後成功脫離呼吸器之護理經驗

The Nursing Experience of Successful Weaning for a Patient with Cervical Spinal Cord Complete Injury

本文旨在描述一位38歲男性，因酒後從5公尺高處摔落至地面，導致第四、五節頸椎脊髓神經完全損傷，協助個案術後成功脫離呼吸器之護理經驗。護理期間自2019年1月3日至2月20日，筆者運用Gordon十一項健康功能型態為評估工具，藉由會談、觀察、身體評估及查閱病歷方式收集資料，確立個案主要的護理問題為呼吸器戒斷反映功能失常、身體活動功能障礙及無力感。護理過程中提供個別性護理，協同呼吸治療師、營養師、復健師、社工師等專業團隊共同擬定及執行肺部復健計畫與呼吸器戒斷計畫，促進肺擴張及維持正常的血氧飽和濃度，最後協助個案成功脫離呼吸器。同時協助個案進行床邊肢體復健運動，促進四肢肌肉力量改善，以及運用主動關懷、傾聽及引導個案表達需求與內心感受，強化激勵正向的想法，引導個案以解決問題為導向的正向思維及提升自我控制感，最後個案能以正向的態度面對後續之復健治療。

This article aims to describe a 38-year-old man who fell to the ground from a height of 5 meters after drinking, suffered from 4th to 5th cervical spine complete injury, and documents the nursing experience of successfully helping a patient weaning from a mechanical ventilator. The nursing period was from January 3 to February 20, 2019. Data was collected by observation, interview, physical examination, and chart review. Gordon's 11 functional health patterns were applied for systemic evaluation. Three nursing problems were identified, including dysfunctional ventilatory weaning response, impaired physical mobility, and powerlessness. Provide individual care during the nursing process, cooperate with respiratory therapist, nutritionist, rehabilitation specialist, social worker and other professional teams to jointly develop and implement pulmonary rehabilitation and ventilator withdrawal program to promote lung expansion and maintain normal blood oxygen saturation concentration, and finally help the patient to successfully weaning from the ventilation. At the same time, assist the patient to perform bedside limb rehabilitation exercises to promote the improvement of muscle power of the limbs, and use active caring, listening, and guiding the patient to express needs and inner feelings, strengthen positive thoughts, and guide the patient to solve the problem-oriented positive thinking, and enhance self-control. Finally, the patient can face the subsequent rehabilitation treatment with a positive attitude.