一位溺水導致急性肺損傷病人之急診護理經驗

The Emergency Nursing Experience of a Patient with Acute Lung Injury due to Drowning

劉致如(Chih-Ju Liu) ； 徐梅玉(Mei-Yu Hsu) ； 陳明婉(Ming-Wan Chen)

《高雄護理雜誌》 31卷2期 (2014/08) Pp. 35-44

https://doi.org/10.6692/KJN-2014-31-2-4

摘要

本文探討一位溺水導致急性肺損傷病人於急診求醫過程，因疾病及醫療引發生心理之相關健康護理問題。照護護理期間為2012/7/20~7/25，過程藉由身體評估、觀察及筆談等方式收集主客觀資料，以Gordon十一項健康功能評估，確立問題為氣體交換障礙、照顧者台東金城武樹角色緊張、焦慮。針對上述健康問題提供個別性護理措施：衛教腹式呼吸、調整呼吸器呼氣末正壓及氧氣濃度，進而改善氣體交換障礙；照護期間感到家屬緊張自責，藉由護理指導及參與照護，使之渡過低潮；經傾聽、設定共通肢體語言及放置溝通板，減輕病人焦慮。在醫療團隊照護下，病人順利移除氣管內管，期望藉此護理經驗能提供臨床急診護理人員參考，不僅解決生理問題，更著重心理層面，以達到整體性護理。

關鍵字

溺水 ； 急性肺損傷 ； 焦慮 ； 護理

並列摘要

This article discusses the process of emergency medical treatment process of a patient with acute lung injury due to drowning of which physiological and psychological health issues have arisen due to the disease itself and the medical treatments received. Nursing care was provided over a period from the 20th to the 25th of July 2012, and objective and subjective findings were collected via participants of the nursing care process using physical evaluations, observations, surveys and interviews. Gordon's 11 functional health patterns were used for a general evaluation and the issues involved for the case included: Impairment of gas exchange; Stress of care provider; and Anxiety. Nursing care was provided with respect to the aforementioned health issues, which included: abdominal breathing education for the patient, adjustment of Positive End Expiratory Pressure and oxygen concentration of ventilator at appropriate times, in order to improve the condition of gas exchange impairment. Self-denial and anxiety were both experienced by the family members as well during the process and nursing guidance was provided, and they were invited to participate in the nursing process to help them overcome stress. In order to reduce the anxiety of the patient, the nursing personnel listened attentively to the needs of the patient, while common body language and conversation boards were used for communication. Weaning was successful under the combined care of the medical team, and we hope to use the experience obtained from this case as a reference for clinical nursing personnel in ER settings for the future care of patients with similar disease. The emphasis lies not only on the resolution of physiological issues, but also on healthcare with regards to the psychological status of the patient in order to achieve an all-round and thorough nursing care.

並列關鍵字

Drowning ； acute lung injury ； anxiety ； nursing