一位顱動脈瘤破裂日籍患者行血管栓塞術後的加護經驗

An Intensive Nursing Experience of Caring for a Post-Operative Patient with Intracranial Vascular Thrombosis

本文描述一位70歲日本籍女性因腦動脈瘤破裂造成顱內出血，術後併發再出血及血管痙攣的加護病房護理經驗，護理期間自2010年12月17日至2011年1月11日。藉由和家屬會談、導遊協助翻譯、翻譯軟體及手冊、觀察、身體評估及Gordon十一項健康功能型態評估收集資料，確立護理問題有呼吸道清除功能失效、顱內調適能力降低、身體活動障礙、言辭溝通障礙。透過有效抽痰，漸進式訓練而脫離呼吸器；嚴密監測腦壓及意識變化，提供安靜舒適環境及分散護理活動，監測腦壓在正常範圍而順利移除腦室外引流管；至少每兩小時協助翻身、胸部物理治療及維持舒適臥位，並以翻譯軟體及中日文對照書籍，教導家屬正確執行被動全關節運動。在護理期間，經歷保住生命，穩定生命徵象，重建最大可能的生命功能，且讓家屬以積極正向的態度面對生活及參與照護，藉此分享此加護經驗，期望有助於提升病人的照護品質。

This article describes an intensive nursing experience of caring for a 70-year-old Japanese woman with intracranial hemorrhage secondary to a ruptured cerebral aneurysm. The patient suffered from post-operative re-bleeding and vasospasm. The nursing period was from December 17, 2010 to January 11, 2011. Through family interview via a tour guide's translation, a translation manual, translation software, patient observation and physical examination, the authors collected required data with Gordon's 11 Functional Health Patterns assessment tool. Based on the analyzed data, the major nursing problems were ineffective airway clearance, decreased adaptability of intracranial capacity, impaired physical mobility and disturbed verbal communication. To wean off the ventilator, the author applied effective sputum suction skills with progressive wean-off training. The patient was closely monitored for abnormal intracranial pressure and mental status change. The patient was provided with a quiet, comfortable environment and had a dispersed schedule for nursing activities. The extra-ventricular drainage tube was smoothly removed when the intracranial pressure was maintained within normal range. In addition, the patient was repositioned for comfort at least every two hours and was offered chest physical therapy for lung clearance. The patient family was taught to perform the correct passive range of motion exercise to keep the patient's muscles from contraction and deformity. During the nursing period, the patient survived with stable vital signs and rebuilt maximal life functions. Additionally, the family members were able to adopt a positive attitude and proactively participate in caring for the patient. The author would like to share this intensive care experience with other nurses with the expectation of promoting quality of patient care.