協助慢性阻塞性肺疾病患者成功脫離呼吸器之護理經驗

This case report describes a ventilator dependant 83-year-old male patient diagnosed with chronic obstructive pulmonary disease. During the weaning process, the patient faced physiological and psychological problems (perceived powerlessness) and his family members faced the pressure of providing him with continuous care. The author provided nursing care from 2008/2/1 to 2008/3/6, which involved observing the patient's condition, interviewing the patient, and using Gordon 11-event functional health pattern assessment guide to evaluate health needs and identify nursing challenges. The challenges found were dysfunctional ventilatory weaning response, activity intolerance, perceived powerlessness, and caregiver strain. The author established a relationship of trust with the patient and his family members while caring for the patient. Based on discussions with the patient entire medical team, we first applied continuous positive airway pressure first for two hours and then increased it by two hours everyday. These two methods were utilized alternately until the case could breathe on his own. Throughout the process, the patient,s vital signs and changes of arterial blood gases were closely observed and the patient was encouraged to get out of bed to do some exercise in order to increase his vital capacity. The author cared for, supported, and listened to the patient and family members, and encouraged them to express their emotions. This was central to both educating the family to improve their patient care regimen and resolve the psychological issues. The author concluded that, when there is a ventilator-dependent patient who needs to be weaned, in addition to providing quality of physical care, nurses should understand and address the psychological dimension of that patient's dependence on ventilation. 本文描述一位83歲男性，患有慢性阻塞性肺疾病，因呼吸器依賴所需進行呼吸器脫離之護理經驗。個案脫離過程除影響生理功能外，還有因呼吸器使用過久所致的無力感心理問題，及家屬照顧上所面對的壓力。故筆者於2008年2月1日至3月6日護理期間，運用觀察法、會談及Gordon十一項功能性健康型態進行評估，發現有呼吸機戒斷反應功能失常、活動無耐力、無力感及照顧者角色緊張等護理問題。照顧期間筆者以持續性護理與個案及家屬建立信任感，並透過醫療團隊的合作與討論，先採壓力支持訓練模式，接著每天增加兩個小時使用持續性正壓呼吸，兩者交替使用，直到個案能自發性呼吸，過程中密切的觀察個案生命徵象及動脈血液變化，並鼓勵下床活動，以增加肺活量，傾聽個案及家屬說出內心的感受，使其得到關懷與支持，激起學習照顧動機與照顧能力，解決因心理因素而影響呼吸器脫離的進展，終能達成個案成功脫離呼吸器。筆者藉此照護經驗分享，讓護理同仁日後面對呼吸器依賴病患需進行脫離訓練時，除提供生理照護外，更深入了解心理層面帶來的影響，以達完整性的照護品質。