一位有機磷中毒併發急性呼吸衰竭之護理經驗

Nursing Experience of a Patient with Organophosphate Poisoning Complicated with Acute Respiratory Failure

10.29494/LN.202212_23(4).0006

蔡上文(Shang-Wen Tsai)；徐淑芬(Shu-Fen Hsu)；馬嘉慧(Chia-Hui Ma)

有機磷中毒 ； 自我傷害 ； 呼吸衰竭 ； organophosphate poisoning ； self-injury ； respiratory failure

領導護理

23卷4期（2022 / 12 / 01）

85 - 99

繁體中文

本文描述一位因工作不順，喝了混有有機磷農藥的高粱酒，導致有機磷中毒合併呼吸衰竭輔助呼吸器入住加護病房之護理經驗。護理期間為2020年6月1日至6月8日，筆者運用Gordon十一項功能性健康評估模式以直接護理、溝通、觀察、身體評估、家屬會談及病歷查閱等方式進行資料收集，確立個案有呼吸道清除功能失效、無效性因應能力及睡眠型態紊亂健康問題。護理期間針對個案呼吸道清除功能失效問題，與醫療團隊共同擬定呼吸訓練計畫，成功幫助個案脫離呼吸器並移除氣管內管，鼓勵個案及家屬說出內心感受，以客觀同理關懷的態度接納正負面情緒，告知疾病進展，增加對疾病認知及控制感並教導情緒管理及壓力宣洩的方法，建立良好護病關係，預防再次自我傷害，促進個案日後面對壓力事件時，能主動尋求資源，以正向因應技巧面對問題。採集中護理，改善睡眠環境，並教導放鬆技巧，增進個案的睡眠品質。期望藉由此護理經驗分享，能提供未來臨床護理人員之參考並提升面對類似個案時之照護能力，促使個案除獲得身心靈之康復外，家屬及個案亦能盡早重新恢復正常生活。

This article describes the nursing experience of an intensive care unit patient who drank sorghum wine mixed with organophosphorus pesticides due to poor work situation, resulting in organophosphorus poisoning and respiratory failure assisted respirator. The nursing period is from June 1st to 8th, 2020. The author applies Gordon's Eleven Functional Health Assessment Model to collect data through direct nursing, communication, observation, physical assessment; family interviews, medical records review, and so on to establish the case encounters nursing problems such as respiratory tract clearance failure, ineffective response ability, and sleep disorder. During the nursing period, we worked with the medical team to formulate a breathing training plan for the patient's respiratory tract clearance failure. Successfully helped the case to get out of the ventilator and remove the endotracheal tube. Encourage the case and family members to express their inner feelings and accept them in an objective and empathetic attitude for both positive and negative emotions. Inform the patient about progress of the disease, increase the awareness and sense of control for the disease, and teach the methods of emotional management and stress relief. Hence, establish a good care relationship, prevent self-harm happening again, and promote the case to actively seek resources when facing stressful events in the future, and face the problem with positive response skills. Utilize intensive nursing care to improve the sleeping environment, and teach relaxation techniques to improve the quality of sleep for the individual. It is hoped that through sharing this nursing experience, it can provide as a reference to future clinical nursing staff to improve the nursing quality when facing similar cases. It can also help the case to recover in terms of physical, mental, and spiritual; in addition the family and the case can return back to normal life as soon as possible.

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