照護一位心因性肺水腫合併急性呼吸衰竭個案之加護經驗

The Nursing Experience of Caring a Pulmonary Edema with Acute Respiratory Failure Case in Intensive Care Unit

10.6386/CGN.202304/SP_34_1.0003

陳宜萱(Yi-Hsuan Chen)；唐敏華(Min-Hua Tang)；郭文英(Wen-Ying Kuo)；張寧郁(Ning-Yu Chang)

肺水腫 ； 氣體交換障礙 ； 體液容積過量 ； 焦慮 ； pulmonary edema ； gas exchange impairment ； body fluid ； overload ； anxiety

長庚護理

34卷增訂刊1（2023 / 04 / 01）

1 - 10

繁體中文;英文

本文描述一位心因性肺水腫合併急性呼吸衰竭個案之加護經驗。因心臟功能衰退，無法有效執行氣體交換，氧合失衡導致呼吸衰竭，接受氣管內插管及呼吸器輔助。護理期間2018年12月25日至2019年1月03日，筆者以Gordon十一項健康功能評估為主軸，運用觀察、筆談溝通、病歷查閱、身體評估及家庭互動等方式收集資料，確立個案有氣體交換障礙、體液容積過量及焦慮等健康議題。透過文獻查證以維持呼吸道通暢及血液動力學穩定，教導橫膈式呼吸，提升肺部通氣功能；藉由每日攝入輸出量統計，教導體液的監控、飲食指導；透過溝通共識、家屬系統支持、配合音樂、按摩，提供靈性支持，給予心靈上的寄託，減輕焦慮感。成功幫助個案緩解生理急症及給予心理支持，順利轉出病房。期望冀此經驗，成為臨床照護之參考。

This paper describes the nursing care experience on a patient with cardiogenic pulmonary edema with the comorbidity of acute respiratory failure. Because of the decline in heart functionality, causing oxygenation imbalance and consequently respiratory failure. The patient received endotracheal intubation and used respirator. The nursing period was from December 25, 2018 to January 3, 2019. The author centered her observation on Gordon's 11 Functional Health Patterns. Methods including observation, communication through writing, case history review, physical evaluation, and family interaction were used to collect data, and the patient was confirmed to exhibit health problems including gas exchange impairment, body fluid overload, and anxiety. According to findings in literature review, the patient's airway was maintained open and his hemodynamic stabilized. The author taught the patient diaphragmatic breathing and chest expansion exercises to increase the gas exchange function of the lung. The author recorded the patient's daily intake and output and taught the patient to monitor body fluid and food intake to prevent excess fluid from accumulating in the body. Through communication, consensus, family support, music, and massage, the patient's attention was diverted. The author also followed the patient's religious belief to provide spiritual support, giving him psychological reliance to reduce his sense of anxiety. The results of this study are expected to serve as a reference for clinical care.

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