協助一位頸椎骨折個案脫離呼吸器的護理經驗

Nursing Experience of a Patient with Cervical Spinal Cord Injury for Successful Weaning from a Ventilator

曲天尚(Tien-Shan Chu)；林慧雯(Huei-Wen Lin)；鄭素月(Sue-Yueh Cheng)

頸椎脊髓損傷 ； 無法語言溝通 ； 脫離呼吸器 ； 護理照護 ； cervical spinal cord injury ； inability to communicate verbally ； nursing care ； weaning from ventilator

志為護理-慈濟護理雜誌

19卷2期（2020 / 04 / 01）

106 - 116

繁體中文

本文旨在描述協助一位頸椎脊髓損傷病人成功脫離呼吸器的護理經驗。2015年8月17日至8月31日護理期間，藉由身體評估、觀察、筆談及Gordon十一項功能性健康型態評估技巧，確立個案有呼吸道清除功能失效、身體活動功能障礙、焦慮及言辭溝通障礙之健康問題。因個案有氣切，無法言語、易嗆到，且四肢活動受限、肌肉萎縮，無法翻身，又因擔心無法順利脫離呼吸器，導致焦慮。護理過程中，藉助圖卡等非語言溝通方式，協助表達需求，並製作抽吸管引流口水，改善呼吸道清除痰液，並藉關懷，先瞭解第一次脫離呼吸器失敗的原因，鼓勵參與解決問題，同時教導家屬有關脊髓損傷後之照護技能。選擇此個案理由是因這一位46歲已婚的脊髓損傷男性，焦慮二度接受呼吸器脫離訓練，可能失敗。經個別化護理，個案順利脫離呼吸器。

This article describes the nursing experience in weaning a quadriplegic male patient, who was unable to communicate verbally, from a ventilator after a cervical spinal cord injury. During the nursing period from August 17 to August 31, 2015, information was collected through physical examination, observation, writing, and Gordon's functional health assessment guide to establish that the patient experienced ineffective airway clearance, diminished physical mobility, anxiety, and impaired verbal communication. Because of the tracheostomy, the patient could not communicate verbally; he was anxious as a result of increased saliva and discomfort when swallowing. We designed illustrated word cards to facilitate the patient's expression of needs and emotions and provided a self-use saliva suction tube to reduce choking and discomfort when he swallows saliva. We clearly explained the weaning procedure, encouraged feedback, provided positive affirmation and support, gave the patient a sense of participation, and taught family members relevant care skills. We share this care experience because this 46-year-old married man with spinal cord injury exhibited anxiety regarding his second weaning; however, individualized nursing care enabled the procedure to proceed successfully.

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