照護一位出血性腦中風病患之加護經驗

The Nursing Experience in a Hemorrhagic Stroke Patient at ICU

本文係描述一位出血性腦中風手術後患者之加護經驗；護理期間自2011 年11月20 日至12 月8 日，個案因出血性腦中風接受開顱手術後入加護病房。筆者於照護期間透過直接照護、身體評估、觀察、會談、病歷查閱等方法，對個案進行生理、心理、社會、靈性整體性評估，彙整相關資料後發現個案有腦組織灌流改變、身體活動功能障礙、身體心像紊亂之健康問題。在護理過程中筆者經由避免顱內壓上升的護理活動來維持正常顱內壓；並與個案建立良好護病關係，藉由家庭系統的支持，協助個案面對身體失能之問題，主動參與復健計畫，增進自我控制感與自信心，讓其適應因疾病造成的生活改變，並以正向態度來面對疾病衝擊。

The purpose of this report was to present the nursing experience and care of a hemorrhagic stroke patient after surgery. The patient had been suffering from a craniotomy and had stayed in the ICU from November 20, 2011 to December 8, 2011. During the period of care, the data were collected for attendance, evaluation, observation, interview, searching medical records, etc. An integral evaluation about the patient’s physiological、psychological、social and spiritual states were also noted. The author noticed the following major nursing problems as shown below: 1.Ineffective tissue/cerebral perfusion 2. Ineffective airway clearance. 3.Body image disturbance. The author provided nursing care to maintain normal intracranial pressure, along with a well-established nurse-patient relationship and provided family support in order for them to face the life style of the patient disabilities. We also actively participated in the rehabilitation treatments to improve self-control and self-confidence. All of these were been done in order to help the patient and family members cope with and adjust their life styles to a more positive attitude in the future.