- 期刊
一位心臟移植後併發肺部感染及急性排斥之護理經驗
Experience of Caring for a Heart Transplant Recipient With Posttransplant Pulmonary Infection
摘要
心衰竭個案於移植手術前因使用心室輔助器致肌無力，於心臟移植手術後，若無執行有效的深呼吸和咳嗽，就易造成肺部感染而引發急性呼吸窘迫，當以呼吸器和抗生素治療仍無法有效控制感染，臨床上則需放置V-V ECMO以維持穩定的氧合功能。當使用體外循環儀器易衍生營養和活動等多重合併症，且長期住在加護病房，易導致個案及家屬情緒調適上的障礙，需要醫療團隊積極的生理和心理的指導和協助。本案為心臟移植手術後因感染和排斥之間未達平衡點，增加了手術後護理的困難度，護理期間為2019年07月25日至2019年10月01日，藉由生理、心理、社會及靈性層面整體性評估，利用觀察、會談及病歷查閱方式收集資料，確立個案有「氣體交換障礙」，「心臟組織灌流不足」，「照顧者角色緊張」等主要健康問題。透過技巧性關懷及有效溝通建立信任的治療關係，建立良好的重症團隊合作模式，增強個案及家屬對診療計畫的認知以及從中達成醫療決策共識，結合藥物及非藥物之護理措施，在使用體外循環儀器當中也可提升舒適感，並密切監測及穩定生命徵象，及時並有效處理併發症。建議針對焦慮不安的家屬，提供規則的家庭會談，利用跨團隊資源，以提升全人護理照顧成效。
並列摘要
The use of a ventricular assist device before transplantation for patients with heart failure causes muscle weakness. Soon after heart transplantation, if effective deep breathing and coughing are not actively or passively performed, pulmonary infection may occur, leading to acute respiratory distress. If such an infection that cannot be effectively controlled, venovenous extracorporeal membrane oxygenation (ECMO) and antibiotic therapy may be clinically indicated for maintaining stable constructive function. The use of an ECMO device can lead to multiple complications affecting recuperation and mobility after transplantation, and a prolonged intensive care unit stay can lead to emotional stress for the patient and family. Patients and families with emotional adjustment disorders need active physical and psychological guidance and assistance from medical teams. In such cases, a balance must be achieved between infection prevention and the likelihood of rejection after heart transplantation, which increases the difficulty of postoperative care. The care period was July 25 to October 01, 2019. Through a holistic nursing assessment of the patient, a nurse identified the following problems: gas exchange disorders, inadequate perfusion of cardiac tissue, and caregiver role tension. We established a trusting therapeutic relationship with the patient through skillful care and effective communication and then reached a consensus on medical decisions, thus establishing a suitable model of critical care teamwork. We recommend conducting regular meetings with family members and utilizing cross-team resources to enhance holistic care.