照顧一位青少年因車禍造成顱內出血術後之加護經驗

A Nursing Experience of a Postoperative Teenage Patient in Intensive Care Unit Suffering from Intracranial Hemorrhage due to Traffic Accident

本文描述一位青少年因車禍造成顱內出血行顱骨切開術後之加護經驗。護理期間2016／8／3至8／26止，以Gordon十一項功能性健康型態評估收集資料，確立健康問題有腦組織灌流改變、組織完整性受損、身體功能活動障礙。照護期間藉由監測生命徵象及神經學徵象預防續發性腦損傷，並促進傷口癒合及觀察有無續發性感染情形；待意識清楚後，提供疾病衛教指導，同時鼓勵個案主動參與自我照顧活動、增加生活控制感；此外因突如其來的重創，使個案正面臨青少年發展階段危機，經由不斷陪伴及鼓勵表達內心感受，使其接納護理人員並願意表達心理感受、配合醫療照護。

The report described a nursing experience of a post-craniotomy teenage patient with intracranial hemorrhage as a result of a traffic accident. The nursing period lasted from August 3 rd to 26 th, 2016. Gordon's 11 functional health patterns was applied to assess the collected data, and the following health problems were confirmed: ineffective cerebral tissue perfusion, impaired tissue integrity, impaired physical mobility, and powerlessness. During the nursing period, the patient's vital and neurological signs were closely monitored to prevent secondary brain injury, facilitate wound healing, and observe signs of secondary infection. Health education was instructed after the patient regained consciousness. The patient was also encouraged to actively participate in self-care activities and regain a sense of control. The patient was facing adolescent development crisis as result of the accidental trauma. With continuous companionship and encouragement on self-expression, the patient fairly accepted the nursing staff. He was willing to express his inner feelings and cooperate with nursing instructions.