運用適應理論照顧一位主動脈剝離病人術後譫妄之護理經驗

Nursing experience of caring a delirium patient post aortic dissection

吳細綾(Hsi-Lin Wu) ； 施孟綾(Meng-Ling Shih)

《長庚護理》 34卷4期 (2023/12) Pp. 120-129

https://doi.org/10.6386/CGN.202312_34(4).0011

摘要

主動脈剝離術後可能併發急性生理與心理不適對醫療照護是一大挑戰。2020年10月29日到11月4日，運用羅氏適應理論進行護理評估，主要健康問題：急性疼痛、呼吸道清除功能失效、譫妄。加護病房屬密閉空間，家屬無法持續陪伴，加上儀器及管路多，病人易感陌生及心理壓力，出現焦慮、躁動，甚至是譫妄，運用放鬆技巧減輕疼痛、教導正確使用誘導式肺計量器、彈性調整會客時間，使家屬陪伴、運用加護病房混亂評估協助譫妄評估、透過跨團隊會議調整治療方向、讓病人及家屬共同參與心臟復健、調整睡眠週期等個別性護理，減輕焦慮，協助儘快恢復健康。

關鍵字

主動脈剝離 ； 譫妄 ； 羅氏適應理論

並列摘要

After aortic dissection, the acute physical and psychological discomfort poses a significant challenge for medical care, emphasizing the critical role of attentive and comprehensive care. From October 29 to November 4, 2020, Roy's adaptation model was employed for nursing assessment, identifying acute pain, respiratory function failure, and delirium as the primary health problems. Intensive care units, being confined spaces, present unique challenges as family members are unable to accompany patients due to various instruments and pipelines. This isolation can lead to heightened susceptibility to strangers and increased psychological pressure. To address these issues, relaxation techniques were implemented to alleviate pain, and the Triflow-II was taught to enhance respiratory function. Meeting times were flexibly adjusted, and family members were encouraged to accompany patients. The use of the intensive care unit confusion assessment for delirium, cross-team meetings to refine treatment approaches, and involving patients and their families in cardiac rehabilitation were instrumental in managing delirium. Additionally, individualized care measures, such as adjusting the sleep cycle, were undertaken to address specific patient needs. These interventions not only reduced anxiety but also contributed to a quicker recovery.

並列關鍵字

aortic dissection ； delirium ； Roy's adaptation model

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