照護一位毛毛樣血管症合併肺炎病人之護理經驗

Nursing Experience for a Patient Suffering from Moyamoya Disease Combined with Pneumonia

本文係描述一位罹患毛毛樣血管症個案，因肺炎引起呼吸衰竭之護理經驗。筆者於2010年1月1日至2月4日護理期間，經會談、觀察、身體評估等直接照護方式，對病人進行完整性評估，發現個案有：現存性感染、氣體交換障礙及照顧者角色緊張等健康問題。護理過程中為強化重症照護之靈性照護目標，選擇Watson理論十項關懷照護因子，作為護理措施架構。藉由噴霧治療、背部叩擊、姿位引流方式，維持呼吸道通暢及促進細胞氧合，進而改善肺部感染症狀；在生理儀器監測下，採漸進式方式執行呼吸器脫離計劃；透過主動關懷、傾聽、鼓勵照顧者表達內心感受，提供正確資訊，減輕其緊張程度並有信心參與照顧。筆者由此照護經驗深刻體會護理師不僅照護病人，更須涵蓋照顧者，提供完整性家庭支持系統，發揮護理獨特功能，以提升護理專業之照護品質。

This case study presents a nursing experience of a patient with moyamoya disease suffering from respiratory failure caused by pneumonia. A full nursing assessment was conducted through interviews, observations and physical assessments during a period of care from the fi rst of January to the fourth of February in 2010. The patient's health issues were identifi ed as existing infection, gas exchange impairment and caregiver role strain. To strengthen the spiritual care during critical nursing, Watson's theory was applied as the framework. The interventions comprised of improving pulmonary infection symptoms by using aerosol therapy, back percussion, postural drainage to maintain smooth airways and facilitate cellular oxygenation; implementing progressive ventilator weaning with the monitoring of physiological instrument; reducing stress and increasing the confidence of the caregiver while participating in the patient care via positive regard, listening, encouraging expression of feelings and providing information. Throughout the nursing experience, it is realized that nurses not only look after patients but also the caregivers, which need to provide a holistic family support system enhancing the quality of nursing care.