協助一位再次氣切老年病人出院準備之經驗

A Nursing Care Experience of Discharge Planning Service for Elderly Patient Receiving a Redo Tracheostomy

10.6740/NTUHJN.202007_16(2).0003

朱梅綾(Mei-Ling Chu)；陳燕雅(Yen-Ya Chen)

年長者 ； 氣切 ； 出院準備 ； 照顧者角色緊張 ； elderly patient ； tracheotomy ； discharge planning care ； caregiver role strain

臺大護理雜誌

16卷2期（2020 / 07 / 01）

17 - 28

繁體中文

本文描述照護一位再次氣切老年病人因自我照顧能力降低，社會資源缺乏，藉由護理照護過程提供出院後連續性照顧之經驗。照護期間自2017年7月18日至8月17日，藉由直接照護、筆談、觀察、身體評估與病歷查閱等方式收集資料，依據紐曼系統理論（Neuman's systems model）進行護理評估及訂定護理措施。確立主要健康問題包括呼吸道清除功能失效、自我照顧能力缺失及照顧者角色緊張等。於出院準備過程中，主動關懷個案情緒，教導其有效性咳嗽，增進自我照顧能力；同時為減輕照顧者壓力，運用衛教單張及操作示範衛教主要照顧者學習抽痰、灌食等返家後照顧技巧，並經由回覆示教評值主要照顧者學習成效。出院前協助用物準備及轉介居家護理所，個案於出院前能參與部分自我照顧活動，增加自我控制感，出院後電話追蹤返家照護情況。建議臨床護理人員對於照顧年長且出院仍需管路照護的病人，能以全家照護觀點與醫療團隊人員一起協助病人出院準備相關事宜，及結合長期照顧資源，進而提升病人及照顧者的生活品質，降低病人再入院率。

This article described an elderly patient with a redo tracheostomy required further discharge planning nursing care because of disability in self-care and a lack of social resources. Data were collected from July 18 to August 17, 2017 by direct care, writing, observation, physical examination, and medical record review. After nursing assessment based on Neuman systems model, the health problems were identified: ineffective airway clearance, self-care deficits, and caregiver role strain. The aims of nursing care were to increase the patient's ability of self-care, and his family members' ability of providing care at home effectively, and improved the patient's sense of self control and his family's burden. It is recommended that a family-oriented nursing care with cooperation with medical team members and providing long-term care resources can improve the patient's and his family's quality of life, and can reduce the readmission rate.