運用ABCDEF組合式照護於呼吸衰竭個案之加護經驗

The Nursing Experience of a Patient with Respiratory Failure: an Application of ABCDEF Bundle Care

10.6692/KJN.202404_41(1).0007

許雅雯(Ya-Wen Hsu)；王淑娟(Shu-Chuan Wang)；朱璧岑(Pi-Chen Chu)

ABCDEF組合式照護 ； 呼吸衰竭 ； 重症照護 ； ABCDEF bundle care ； respiratory failure ； critical nursing care

高雄護理雜誌

41卷1期（2024 / 04 / 01）

86 - 97

繁體中文;英文

本文描述一位肺腺癌併發肺炎導致呼吸衰竭個案之加護病房照護經驗，個案因生命受到疾病威脅、標靶藥物副作用引發身體外觀改變，造成生、心理層面的壓力與衝擊。護理期間為2019年6月8日至6月20日，筆者藉由身體評估、觀察、筆談、會談及病歷查閱等方式收集資料，進行生理、心理、家庭、社會及靈性之整體性護理評估，確立個案的健康問題為呼吸道清除功能失效、身體心像紊亂及焦慮。護理過程中，運用ABCDEF組合式照護措施協助個案順利脫離呼吸器；提供標靶藥物副作用相關衛教與照護措施，協助個案調適與重建信心；以同理心、主動關懷、傾聽、陪伴及筆談建立良好護病關係，引導個案表達心中感受及困擾，緩解其焦慮程度。希望藉此護理經驗分享，提供日後重症護理師於臨床實務照護之參考。

This article described a nursing experience of a patient with respiratory failure due to lung adenocarcinoma and pneumonia in the intensive care unit. The patient was faced with physical and psychological impacts because of life-threatening condition and adverse effect in target therapy. During the nursing period from 8th June to 20th June, 2019, for the purpose of completing systematic assessment of physical, psychological, family, social and spiritual aspects of health issues. We collected the data from various aspects including the physical assessments, observations, conversations by writing, interviews and medical clinical records. The health problems included ineffective airway clearance, body image disturbance and anxiety. We applied the ABCDEF bundle care to help the patient wean from mechanical ventilation successfully, provided the health education and care about adverse effect of target therapy to help the patient adaptation and restore self-confidence. We also established a good nursing-patient relationship, provided caring, listening, accompanying, and encouraged the patient expressing her feelings to reduce the anxiety level. The authors would like to share this case report to critical nursing professionals as reference.

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