早期介入一位腦出血患者之照護經驗

The Nursing Experience of Taking Care of a Brain Hemorrhage Patient with Early Intervention

本文為一位腦出血患者於加護病房期間之護理經驗。個案是一位獨力扶養其外孫的中年女性，當個案意識恢復清楚後，發現身體偏癱而出現害怕、無助、落淚之情緒，引發筆者運用早期介入來幫助個案之動機。護理期間自2008年6月20日至2008年7月4日，筆者藉直接護理、會談、檢驗報告、觀察等方式，運用Gordon十一項功能性健康型態評估，發現個案於加護單位急性期主要護理問題為呼吸道清除功能失效、潛在危險性感染、身體活動功能障礙、及身體心像紊亂。經由筆者透過護理過程，與醫師、呼吸治療師、專科護理師及護理同仁等醫療團隊，運用適當醫療措施及護理措施，協助病患恢復健康、減低心理障礙，進而發揮身體殘障肢體的最大可運用性。期望此護理經驗能提供日後早期介入腦出血患者相關照護之參考。This article described the experience of taking care of a brain hemorrhage patient with early intervention. The patient is a middle-age female and brings up her grandson alone. It induced the author to help the client by early intervention when the patient recovered from her consciousness, showing emotions of fear, helplessness and weep after detected hemiplegia. The patient's information was collected from Jun. 20th to Jul. 4th 2008 from the author's direct care, observations, interviews and laboratory data. Four major nursing problems: ineffective airway clearance, potential infection, impaired physical mobility, and body image disturbance were evolved from Gordon 11-item of functional health assessment when patient was in the intensive care unit. Clinical team helped the patient with the appropriate nursing process and multidisciplinary collaboration to regain health, reduce psychological disturbance, and reestablish the function of affected limb through early medical and nursing intervention. This nursing experience demonstrated a good example of early intervention in the nursing care of brain hemorrhage patients.