一位心因性休克合併使用主動脈內氣球幫浦病人之加護經驗

Nursing Experience of Caring a Cardiogenic Shock Patient with Intra-aortic Balloon Pump in the ICU

10.6530/YYN.2011.5(2).09

歐羽珊(Yu-Shan Ou)；陳淑媚(Shu-Mei Chen)；袁玉萍(Yu-Pieng Yuan)

心因性休克 ； 主動脈氣球幫浦 ； 重症照護 ； cardiogenic shock ； intra-aortic balloon pump ； critial care

源遠護理

5卷2期（2011 / 11 / 01）

63 - 71

繁體中文

本文敘述照顧一位急性心肌梗塞導致心因性休克之重症病人，經過急救後裝置主動脈內氣球幫浦（intra-aortic balloon pump, IABP）輔助循環之護理經驗。筆者於2008年11月22日至2008年11月26日護理期間以觀察、身體評估、會談及筆談等技巧收集資料，並運用Gordon十一項健康功能型態評估確立個案各項健康問題，包括心肺組織灌流改變、潛在危險性傷害、焦慮等問題。護理過程中，首先藉由積極密切的治療以穩定其血液動力學之變化，並提供合宜適切的護理措施以避免個案產生各項合併症，其次面對其極度焦慮的情緒行為反應，筆者採用語言及非語言的溝通方式、運用同理心、情緒支持等措施，終以改善個案之焦慮情形。臨床上面對此類重症病患，提供病人基本生理照顧、合宜護理照護及心靈層面之需求均仰賴著護理人員的專業，希冀藉此護理經驗分享，提供護理人員日後照護此類病人之參考，進而提昇病人之照護品質。

This article discusses the critical nursing care experience of a patient who received intra-aortic balloon pump (IABP) post initial resuscitation from AMI-induced cardiogenic shock. Data was collected during a 5-day period through observation, physical assessment, interviews and written communication. Gordon's 11 function heath patterns assessment identified the patient's three major health problems: (1) cardiopulmonary perfusion alterations, (2) potential hazardous injury, and (3) anxiety. Initial nursing interventions followed intensive care medical treatments to stabilize hemodynamic status and to prevent complications. Measures to reduce the patient's anxiety included verbal and non-verbal communication, empathy, and emotional support. Domains of professional nursing care included basic nursing care and a holistic approach addressed the patient's spiritual needs.