照護一位皮肌炎個案脫離呼吸器之護理經驗

Nursing Care Experience of a Patient with Dermatomyositis Deliberating from a Mechanical Ventilator

10.6540/NTJN.2016.1.008

李幸玫(Shing-May Li)；王筱珮(Shiao-Pei Wang)

皮肌炎 ； 吞嚥困難 ； 吞嚥訓練 ； 無力感 ； Dermatomyositis ； Dysphagia ； Swallow training ； Powerlessness

新臺北護理期刊

18卷1期（2016 / 03 / 01）

93 - 101

繁體中文

本文主要為探討一位48歲女性個案，因皮肌炎導致吞嚥困難而嗆咳，引起吸入性肺炎之照護經驗。護理期間自2013年8月21日至9月2日，筆者藉由直接照護、觀察、會談、傾聽、身體評估等方式收集資料，依Gordon十一項健康功能型態進行整體性評估，確認個案有呼吸道清除功能失效、吞嚥困難、無力感等護理問題。在護理過程中，透過個別性、持續性的護理措施，與醫療團隊共同努力，鼓勵個案積極參與治療、正視自己的需求及表達內心的感受；教導在吞嚥訓練過程中，以漸進方式由口進食軟質食物，進食時採坐姿，避免食物誤入呼吸道，並且教導胸腔復健運動，以利痰液排出，預防併發症產生；透過主動關懷及傾聽個案表達內心感受，鼓勵家人陪伴給予正向支持，增加自我照顧能力，降低病人的無力感。經由上述護理措施的提供，病人於9月2日成功脫離呼吸器，順利轉至一般病房。皮肌炎是一種慢性疾病，除了急性的照護外，後續的照護也相當重要，故希望藉由此個案的照護經驗，提供臨床護理師照護此類個案之參考。

This case report is about the experiences of caring for a 48-year-old female who had aspiration pneumonia after dysphagia and choking due to dermatomyositis. Patient's data were evaluated based on eleven Gordon's Functional Health Patterns tool and collected by direct nursing care, observation, communication, listening, and physical examination from 21st August to 2nd September, 2013. Through the assessment, the nursing issues of ineffective airway clearance, dysphagia and powerlessness were identified. During the nursing process, continuous and individualized nursing intervention was implemented, including cooperating with team members and encouraging the patient to involve in the care and express her needs and feelings in mind. The swallow training was carried out and taught patient eating soft diet progressively and keeping upright sitting position to prevent aspiration. Chest physiological therapy was also executed to facilitate sputum clearance and prevent advanced complications. Through concerning and listening the patient's feeling in mind and encouraging families accompany and positive support, it enhanced the patient's self-care ability and reduced her powerlessness. As a consequence, this patient was weaned off the ventilator on 2nd September, and transferred to general ward smoothly. Dermatomyositis is a chronic disease. The long-term care is equally important to the acute care. We share this experience and hope that it serves as a reference for nurses while caring for this kind of patients.

1. Chang, H. C.,Wu, Y. J. J.,Luo, S. F.,Ho, H. H.,Liou, L. B.,Chen, J. Y.,Yu, K. H.(2010).Prognostic factors of survival in patients with dermatomyositis and polymyositis.Formosan Journal of Rheumatology,24(1 & 2),29-35.
2. Fang, Y. F.,Luo, S. F.,Kuo, C. F.,Ho, H. H.,Liou, L. B.,Chen, J. Y.,Yu, K. H.(2012).Clinical presentations associated with anti-Jo-1 antibody in patients with polymyositis and dermatomyositis.Formosan Journal of Rheumatology,26 1(1 & 2),15-22.
3. Kuo, H. H.,Chang, H. C.,Wu, Y. J. J.,Luo, S. F.,Ho, H. H.,Liou, L. B.,Yu, K. H.(2011).Predicting factors of malignancy in inflammatory myositis.Formosan Journal of Rheumatology,25(1 & 2),27-34.
4. 呂沛晴,戴美玲(2010)。一位慢性阻塞性肺疾病病人無力感之護理經驗。澄清醫護管理雜誌，6(4)，39-45。
5. 李怡靜,侯慧明(2012)。照顧一位皮肌炎年輕女性個案之護理經驗。榮總護理，29(3)，261-266。
6. 林詩淳,蔡坤維,江瑞坤,范國聖(2008)。老年人的肺炎及預防護理。志為護理，29(3)，60-70。
7. 唐善美(2004)。淺談皮肌炎。慈濟護理雜誌，3(4)，24-28。
8. 張家如,方宣雅,林雅慧,江東懋,王蓉敏(2011)。一位腦中風合併吞嚥困難病人之護理經驗。志為護理，10(4)，96-108。
9. 張惠如,邱月秋,高本蓉,李玉秀(2009)。提升病患成功脫離呼吸器之專案改善。長庚護理，20(4)，471-484。
10. 許欣虹,廖貴香(2012)。一位48小時非計劃性重置氣管內管病患之加護經驗。領導護理，13(1)，35-43。
11. 陳嘉偉,蔡呈芳,陳佑甫,洪志明(2007).Dermatomyositis presenting with erythroderma: A case report.中華皮膚科醫學雜誌,25(3),200-204.
12. 葉月珍,馬素華(2002)。「無力感」之概念分析。長庚護理，13(2)，146-151。
13. 廖振羽,林怡芬,陳建仲,王人澍(2012)。多發性肌炎併肺炎呼吸衰竭之中西醫結合治療病案與病機推演。中西整合醫學雜誌，14(4)，47-58。
14. 蔡恒惠(2012)。高齡者與住院病患的口腔照護。新台北護理期刊，14(1)，1-5。
15. 賴怡君,王桂芸,陳金彌(2011)。吞嚥困難之概念分析。源遠護理，5(2)，56-62。