This article discusses the nursing experience caring for a 19-year-old man with traumatic C4-6 cervical injury who had been placed on a respirator and was to receive respiratory training between 2009 February 12 to March 2. Using Gordon 11 functional health assessment and observation, interview, medical records, direct care, and assessment of skills, the problems of the patient were found to be respiratory dysfunction, anxiety, and deficiency in self-care ability. The nursing problems were confidence building, progressive respiratory training, and ventilator weaning. Active and empathetic attention and care were provided to the patient and his family members. Encouragement was used to build self-confidence, reduce the use of the respirator, and reduce anxiety. The patient was actively encouraged to receive physical rehabilitation to maintain and re-gain muscle strength for out of bed functions. The family members were instructed on how to teach cognitive skills, enhance his self-care ability and assist in his progressive weaning from the ventilator.
本文是探討一位19歲因車禍導致C4-6頸椎損傷接受呼吸訓練的護理經驗，依Gordon十一項功能健康型態，針對個案進行整體性評估，護理期間自2009年2月12日至3月2日，照護過程中運用觀察、會談、直接護理及病歷查閱等評估技巧及由案姐協助下以唇語、臉部表情表達進行資料收集，確立病患主要護理問題為：呼吸器戒斷功能失常、焦慮、自我照顧能力缺失。在照護期間依據呼吸器脫離之流程執行護理計畫，並依個別性採全人照護與病患建立信任感，採漸進式呼吸訓練，協助進行呼吸器脫離；透過主動關懷、同理心等技巧，給予家屬及病患支持與鼓勵，以建立自信心，減輕病患及家屬對使用呼吸器及疾病復原所產生的焦慮，運用復健運動促進病患維持肌肉力量，並採漸進式下床活動，強化肢體剩餘功能，教導家屬對後續照護技巧認知上的熟悉，促使提升自我照顧能力，進而協助漸進式訓練讓個案成功脫離呼吸器。
