運用共享決策於一位肺癌脫離呼吸器個案之護理經驗

Nursing Care Experience of Shared Decision-Making for Weaning a Lung Cancer Patient from a Mechanical Ventilator

張寶綾(Bao-Lin Chang) ； 陳瑞儀(Jui-Yi Chen) ； 周昭伶(Chao-Ling Chou) ； 陳玉萍(Yu-Ping Chen) ； 高秀娥(Hsiu-O Kao)

《澄清醫護管理雜誌》 15卷2期 (2019/04) Pp. 66-74

摘要

本文係照護一位77歲肺癌合併肺炎個案，面臨接受氣切決策及脫離呼吸器之護理經驗。護理期間為2016年12月29日至2017年1月25日，筆者依個案生理、心理、社會與靈性等層面進行整體性評估，發現個案有呼吸道清除功能失效、傷口疼痛、知識缺失及無力感之護理問題。在照護期間除了依個別化呼吸器脫離流程執行護理計畫，加強心肺復健促進肺部擴張，進而強化呼吸肌力及提升痰液清除能力。因氣切術後傷口疼痛，藉由止痛藥和看電視節目轉移注意力，達到疼痛控制。陪伴個案與家屬面對氣切之決策歷程時，藉由氣切決策影片了解氣切的優缺點，鼓勵個案抒發內心感受，減少低落情緒和面對氣切的無力感。整合跨團隊合作和臨床倫理委員，讓個案充分了解目前疾病治療與進展，最後個案接受氣切手術，並於2017年1月25日成功脫離呼吸器。建議無法脫離呼吸器的病人，儘早提供氣切決策影片，以利成功脫離呼吸器改善生活品質。

關鍵字

脫離呼吸器 ； 呼吸衰竭 ； 肺癌 ； 氣切 ； 共享決策

並列摘要

This case report describes the nursing care experience of a 77-year-old patient with lung cancer and comorbid pneumonia faced with decisions regarding tracheotomy and mechanical ventilator weaning between December 29, 2016 and January 25, 2017. Integrated assessment of the physiological, psychological, social, and spiritual aspects was carried out. The patient had impaired respiratory clearance functions, wound pain, lack of knowledge, and feelings of helplessness. In addition to planned nursing care based on an individualized weaning protocol, the patient also received cardiopulmonary rehabilitation to enhance pulmonary expansion and improve respiratory muscle strength and sputum clearance ability. Owing to wound pain after the tracheotomy, analgesics were provided to achieve pain relief and watching television programs served as a distraction from her pain. We assisted family members during the decision-making process for tracheotomy by presenting to them and the patient a video on tracheotomy so that they could understand the pros and cons of this procedure. They were also encouraged to express their feelings to help them cope with the patient's low mood and sense of helplessness. Furthermore, interprofessional team and clinical ethics committee members provided opportunities for the patient to fully understand her existing disease treatment and progress. The patient finally agreed to undergo a tracheotomy and was successfully weaned off the ventilator on January 25, 2017. We recommend that patients with respiratory failure who are unable to be weaned off the ventilator should view a video on tracheotomy as soon as possible to facilitate the process of successful weaning off the ventilator and improve their quality of life.

並列關鍵字

Mechanical ventilator weaning ； Respiratory failure ； Lung cancer ； Tracheotomy ； Shared decision-making