一位血液透析病人於腸道術後呼吸器脫離困難之護理經驗

Nursing Experience of a Difficult-to-wean Patient on Dialysis Undergoing Major Abdominal Surgery

10.3966/172674042018031701007

李玉英(Yu-Ying Li)；林家慧(Jia-Huei Lin)；陳美娟(Mei-Chuan Chen)

血液透析 ； 呼吸衰竭 ； 營養不良 ； hemodialysis ； respiratory failure ； malnutrition

臺灣腎臟護理學會雜誌

17卷1期（2018 / 03 / 01）

86 - 102

繁體中文

本文描述血液透析長者，因腸道手術後併發呼吸衰竭，協助其呼吸器脫離照護經驗。護理期間2014年12月5日至2014年12月25日，以Gordon十一項功能性健康型態評估，健康問題：因術後臥床及禁食使身體機能下降，肌肉質量流失而影響呼吸肌功能，加上體液調節失能造成全身性水腫，增加呼吸負荷，產生低效性呼吸型態；術後營養吸收及攝取受限導致營養少於身體需求；在心理衝擊方面，因歷經呼吸器脫離失敗，失去對身體控制感而產生無望感，出現情緒困擾無法配合呼吸訓練，曾自行拔除氣管內管，使得呼吸器脫離的困難度增加，筆者透過建立信任感、傾聽、陪伴及溝通技巧，協助以正向態度面對呼吸器脫離過程，運用整合團隊照護，採漸進式增加灌食熱量及配方調整，增加營養攝取，照會物理治療師共同執行復健運動，提升活動肌耐力，幫助個案脫離呼吸器。在文獻搜尋閱讀的過程中，有感於血液透析病人相關呼吸器脫離的照護文獻較少，期望藉此經驗分享，提供護理同仁參考，以提升護理品質。

This article described the nursing experience of a chronic hemodialysis elderly patient with respiratory failure after an intestinal surgery to successfully weaned from the ventilator. The nursing period was from December 5 to 25, 2014. Based on Gordon's eleven functional health patterns, the author collected the data in this article by means of observation, physical evaluation, medical records, and interviews with family members. The major health problems were postoperative bed rest and fasting-state-reduced the physical functions, insufficient muscle endurance caused by muscle mass loss and affecting the respiratory muscles, dysregulation of body fluid resulting in systemic edema and increasing respiratory load and ineffective breathing pattern, limited postoperative nutrient uptake and absorption leading to poor nutrition than physical needs. In terms of psychological impact, the patient experienced weaning failure and she felt loss of control of her body and developed a sense of hopelessness. She had emotional distress and could not cooperate with respiratory training exercise and tried self-removal of the endotracheal tube. All of these increased the difficulty of weaning process. We established a trust relationship with the case by listening and accompanying and communication skills, and encouraged the patient to face the weaning process with a positive attitude. Under an integrated medical care plan, the patient increased her intake and absorption of nutrients by progressively caloric uptake and formula adjustment. The physical therapist designed and performed the rehabilitation exercises for the patient to enhance physical activity and muscle endurance for ventilator weaning. While searching and reading references, the author found that there were limited articles on the weaning process for hemodialysis patients. The author hopes to share this experience with clinical nursing staffs as a reference and to improve nursing care quality.

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