本報告係照護一位69歲氣喘患者因反覆呼吸道感染、咳嗽厲害合併夜間喘鳴而入院接受治療之護理經驗。護理期間(94年12月13日至12月17日)運用Gordon十一項功能性健康型態評估,藉由觀察、會談、身體評估等方式收集資料,確立個案主要健康問題為:知識缺失、服藥不遵從、呼吸道清除功能失效、焦慮等;筆者因有感個案反覆就醫,造成其身、心諸多影響,也增加醫療成本的耗費,故護理過程中透過主動關懷,建立良好護病關係,提供個別性的護理需要及指導,引導病人獲取更多正確氣喘照護的資訊及正確技巧運用,以減輕個案於住院期間因急性發作產生的不適症狀,及疾病所帶來的困擾,並於出院後繼續電話追蹤回診,以確定個案能接受及執行護理指導,進而改善生活品質。藉由此護理經驗之分享,期望提供護理人員未來照護此類患者之參考。
This report describe the nursing experience of a 69 years old patient who suffer for nighttime severe coughing and re-infection respiratory tract. During the period (December 13 to December 17, 2005), the author through observation, interview, and physical examination, used by Gordon 11 healthy functional evaluation tool to collected data. The main healthy problems were as follow : Knowledge deficit, Noncompliance to medicine , Ineffective airway clearance ,and Anxiety etc. Through establish good nurse patient relationship and active caring, The author applied individual and general nursing , to help patient gain a lot of correct information and caring technique about asthma, decrease uncomfortable symptom in hospitalization. By nursing this patient, the author indicate that we should provide discharge planning services, then improve the quality of asthma patient life. Expect we hope to share nursing experience with asthma to another nursing staffs.