照護一位淋巴血管平滑肌增生病人行肺臟移植術後合併乳糜胸之加護照護經驗

本文描述一位淋巴血管平滑肌增生症病人接受肺臟移植手術後，併發乳糜胸之照護經驗。個案術前即有營養失衡及活動無耐力之健康問題，肺移植術後需大量復健，但因出現吞嚥障礙及乳糜胸導致熱量攝取不足，加重活動無耐力情形，延遲復健進度，為選案動機。2019年5月30日至8月8日護理期間，以Gorden 11項健康功能型態進行評估，並以觀察、會談及病歷查閱方式歸納出營養少於身體需要、活動無耐力、焦慮等健康問題。針對肺移植術後需大量活動而熱量需求增加，但術後吞嚥困難及乳糜胸導致營養少於身體需要，藉吞嚥訓練、無油飲食、藥物治療及個別性飲食指導，成功控制乳糜胸之情形，並建立正確飲食習慣，達足夠熱量攝取；在活動無耐力及對復健運動不適應部份，運用自我效能理論及個別性運動計畫如：有氧舞蹈及瑜珈，增進移植術後心肺功能，改善活動無耐力；移植後需終身服用免疫抑制劑及乳糜胸合併症引起個案焦慮，藉由藥物及飲食指導並回覆示教，改善不安情緒。移植術後須跨領域團隊合作以提供完整照護計畫，建議將ABCDEF Bundle導入重症照護，透過家屬賦權參與早期照護復健，改善重症病人心肺耐力，提升照護品質。

關鍵字

肺臟移植； ABCDEF Bundle ；營養少於身體需要；活動無耐力；焦慮

並列摘要

This article describes the nursing care for a patient with lymphangioleiomyomatosis and chylothorax after lung transplantation. Before the surgery, the patient had imbalanced nutrition and activity intolerance. After lung transplantation, the patient required extensive rehabilitation. However, the patient suffered from swallowing disorders and chylothorax, which led to insufficient calorie intake, aggravated activity intolerance, and delayed rehabilitation progress. Based on these reasons, the authors were motivated to choose this case. Information regarding the patient's health condition was collected from May 30 to August 8, 2019, using direct observation, interviews, reviewing medical records, and physical assessment. According to Gordon's 11 functional health patterns, the three major healthcare problems experienced by the patient were identified as imbalanced nutrition, activity intolerance, and anxiety. After lung transplantation, several activities are required and there is increased demand for calories. Thus, complications associated with dysphagia and chylothorax can lead to a lack of nourishment in the body. However, the occurrence of chyle leakage was successfully controlled using swallowing training, an oil-free diet, medication, and individual diet guidance. Furthermore, the patient was facilitated to develop the correct eating habits to achieve an adequate dietary intake. Implementing the self-efficacy theory and individual exercise plans, such as aerobic dance and yoga can improve cardiopulmonary function after transplantation and activity intolerance. Furthermore, immunosuppressive drugs are required permanently after transplantation as chylothorax with comorbidities can cause anxiety in this case. Moreover, medication, dietary guidance, and replying to teaching, reduced anxiety in the patient. We suggest that caring for critically ill patients can be discussed through multidisciplinary cooperation to provide a complete care plan and use the ABCDEF bundle in intensive care. To promote other critically ill units through family empowerment to participate in early mobilization, improve cardiorespiratory function in critically ill patients, and improve the quality of intensive care.

並列關鍵字

lung transplant ； ABCDEF bundle ； imbalanced nutrition ； activity intolerance ； anxiety

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