一位急性炎性脫髓鞘多神經病變病人之護理經驗

Nursing Experience in a Patient with Guillain-Barré Syndrome

鄭淑文(Shu-Wen Zheng) ； 盧彩屏(Tsai-Ping Lu)

《長庚科技學刊》 14期 (2011/06) Pp. 47-56

https://doi.org/10.6192/CGUST.2011.6.14.5

摘要

本文乃照護一位因炎性脫髓鞘多神經病變導效雙下肢乏力、無法行走，而接受血漿置換個案之護理經驗。護理期間筆者經由直接照顧、觀察、會談方式收集資料，以Gordon十一項功能性健康評估分析歸納個案主要護理問題爲高危險性感染、現存皮膚完整性受損、身體活動功能障礙及無望感。筆者運用主動關懷個案建立良好護病關係，透過教導正確照護動靜脈雙迴路導管方法以預防感染；採雙時協助翻身以改善壓瘡；示教主動運動及協助部份被動關節活動，以發揮身體活動之最大潛能；提供相關醫療訊息，使其對治療有正向態度，參與自我照顧活動，以調適疾病過程變化，面對未來的生活。個案無感染、全身皮膚完整無壓瘡，於協助下能自行起身挪至輪椅上、對於疾病的預後及未來，個案表示有信心要很快恢復健康順利出院。照護炎性脫髓鞘多神經病變個案，需有敏銳評估能力，更需具備專業知識與技能及心理層面之輔導技巧，才能提供個案整體性之照護，增進其自我照顧的能力，早日回歸社會，期望此照護經驗能提供往後照護之參考。

關鍵字

炎性脫髓鞘多神經病變 ； 護理經驗

並列摘要

This article describes the nursing experience of a patient who had Guillain-Barré syndrome with the presentation of leg-weakness and an inability to walk. The patient received plasma replacement therapy. The data was collected via direct care, observation, and interviews. The assessment of the patient's condition based on Gordon's eleven functional health indicators showed the main problems in the following: high risk of infection, impaired skin integrity, physical disability, and feelings of hopelessness. A good nurse-patient relationship was established by active care of the patient. Infection was prevented through education about the correct care of an arteriovenous fistula. Pressure sores were reduced by intensified body-position changes. To increase physical fitness, active and passive joint exercises were taught. By being provided with medical information relevant to his condition, the patient had a more positive attitude toward his therapy, and was able to become more adaptive to his disease by participating in self nursing care. Eventually, the patient was free of infection, had intact skin integrity without pressure sores, and could get up and move to the wheelchair by himself. The patient was confident of his future recovery. Keen observation, professionalism, and psychological counseling were all required to provide thorough care of the patient, and they helped the patient to gain the ability to care for himself and to return to society more quickly. We hope this experience can help health-care providers in a similar situation.

並列關鍵字

Guillain-Barré Syndrome ； nursing experience