一位破傷風病人合併肺炎於加護病房之護理經驗

Intensive Nursing Care for a Tetanus Patient with Pneumonia

張方玫(Fang-Mei Chang) ； 黃怡真(Yi-Chen Huang)

《高雄護理雜誌》 37卷2期 (2020/08) Pp. 71-81

https://doi.org/10.6692/KJN.202008_37(2).0007

摘要

本文探討一位破傷風病人接受插管治療後併發肺炎個案，入住加護病房之照護經驗，護理期間自2017年8月29日至9月25日，筆者運用Gordon十一項健康功能型態評估，藉由實際照護、觀察、會談等進行資料收集，確立個案有身體活動障礙、照顧者角色緊張及呼吸道清除功能失效等護理問題。根據病程進展，照護初期減少感官刺激預防痙攣加劇，後期予胸腔物理治療介入，有效清除痰液成功脫離呼吸器轉至病房後出院。過程中面對主要照顧者的緊張情緒，筆者以關懷的態度傾聽心理感受，提供疾病資訊，協助心理調適。本文受限於破傷風相關照護經驗甚少，建議臨床增加案例討論會，由護理師、醫師、營養師與復健師共同擬定具個別性的照護，使個案得到完整且全面性之照護。

關鍵字

破傷風 ； 肌肉痙攣 ； 照顧者角色緊張

並列摘要

This case report explored a nursing care experience for a tetanus patient who required endotracheal intubation and developed pneumonia in the intensive care unit. The nursing care period was from August 29 to September 25, 2017. Data were collected by routine practice, observation and interview, and organized according to Gordon's 11 functional health patterns assessment. As a result, it was identified that the patient had impaired physical mobility, caregiver role strain and ineffective airway clearance. According to the progress of the disease, the initial nursing care reduced the sensory stimulation to prevent muscle spasm, and in subsequent nursing care, chest physiotherapy intervention was performed to clear mucus, effectively contributing to successful ventilator-weaning and discharge after transfer to the general ward. During the care process, in dealing with the caregiver emotional stress, we carefully listened to the caregiver's feelings, provided disease information, and assisted with psychological adjustment. Although this report is limited to the experience of tetanus-related care, it is recommended that increasing the frequency of multidisciplinary case conferences, developing individualized care plans by the physician, nurse, dietitian and providing rehabilitation will all ensure that patients receive comprehensive health care meeting their individual needs.

並列關鍵字

tetanus ； muscle spasm ； caregiver role strain

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