一位肌萎縮性側索硬化症患者併發壓瘡之護理經驗

Nursing Experience of an Amyotrophic Lateral Sclerosis Patient Combined with Pressure Injury

10.6647/CN.201803_25(1).0013

陳嘉帆(Chia-Fan Chen)；鍾玉珠(Yu-Chu Chung)；黃敏鳳(Min-Feng Huang)

肌萎縮性側索硬化症 ； 壓瘡 ； 焦慮 ； amyotrophic lateral sclerosis ； pressure sore ； anxiety

彰化護理

25卷1期（2018 / 03 / 01）

99 - 110

繁體中文

本文旨在描述一位肌萎縮性側索硬化症患者併發壓瘡之護理經驗。護理期間自2016年3月15日至4月4日，藉由溝通、會談、身體評估及查閱病歷方式收集資料，運用Gordon十一項健康功能型態進行整體性評估，確立個案主要的護理問題為呼吸道清除功能失效、皮膚完整性受損及焦慮。護理過程中提供個別性護理措施，藉由胸腔物理治療、手操作腹部推力的技巧及教導腹式呼吸等措施，促進有效咳嗽及痰液之清除，維持呼吸道通暢及血氧飽和濃度大於95%。住院期間提供氧氣治療、傷口護理、協助翻身擺位及執行復健計畫，促進壓瘡傷口癒合。運用主動關懷、陪伴、同理心及傾聽等方式與個案建立信任的護病關係，鼓勵個案說出心裡感受，協助家庭成員之間面對面溝通，減少個案猜忌不安及焦慮情緒，最後個案能接受家屬的出院安排，轉至養護中心，獲得適切性及持續性照護。藉此護理經臨之分享，作為日後照顧此類病人之參考，建議未來此類病人的照護除生理層面的照護外，更應強化心理與靈性層面的護理。

The purpose of this article is to describe a nursing experience of an amyotrophic lateral sclerosis (ALS) patient with pressure sore. The primary nursing period was from March 15 to April 4 in 2016. The authors assessed the patient's health condition by observation, interview, review of medical records and the Gordon functional health assessment guide. Some health problems were identified, including ineffective airway clearance, impaired skin integrity, and anxiety. The authors employed individualized nursing care in the nursing process. Chest physiotherapy, manual abdominal thrust and abdominal breathing were used to promote effective cough and sputum clearance, and maintain airway patency and oxygen saturation greater than 95%. Oxygen therapy, wound care, assisting in the change of position, and rehabilitation programs were performed to promote the wound healing. A therapeutic relationship with the patient was established through active caring, empathy, and listening. The authors also encourage the patient to express her feelings, and help family members to have face-to-face communication to reduce the suspicion and anxiety of the patient. Finally, the patient can accept the discharge arrangement to transfer to the residential institution and acquire appropriate and continuous care. This nursing experience in this article could serve as a reference for caring ALS patients in the future.

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