照護一位顱內動脈瘤破裂患者首次入住加護病房之照護經驗

The Nursing Experience of a Cerebral Aneurysm Rupture Patient with First Intensive Care Unit Admission

本文旨在探討一位顱內動脈瘤破裂致蜘蛛網膜下腔出血個案術後首次入住加護病房之照護經驗。護理期間自2018年11月07日至2018年11月27日，運用羅氏適應模式理論之生理功能、自我概念、角色功能及相互依賴等概念架構，經由觀察、會談、身體評估及病歷回顧等方式收集資料，確立其住院期間主要健康問題為：顱內調適能力降低、低效性呼吸型態、照顧者角色緊張等。針對影響個案適應程度運用護理措施包含提供舒適環境減少過度刺激，監測並執行降低顱內壓相關護理措施；採漸進式進行呼吸訓練，維持呼吸道暢通及胸腔照護；引導家屬情緒給與正向心理支持，依家屬需求運用Ask-Tell-Ask原則提供照護諮詢與共享決策會議，協助個案獲得最適切的個人照護並提供家屬賦權參與，以獲得生理心理層面妥善支持與照護。期能經由經驗分享以提供護理同仁日後面對顱內動脈瘤破裂患者首次入住加護病房，患者及照顧者調適及照護上之參考。

This article described the nursing experience of caring for a patient who was first admitted to intensive care unit with subarachnoid hemorrhage caused by intracranial aneurysm rupture. Roy's Adaptation Model was used as the framework, patient's physiological function, self-concept, role function, and interdependence were collected through observation, interview, physical assessment, and chart review during the period from November 7 to November 27, 2018. We found that the patient suffered from decline of the intracranial adaptation capacity, inefficient breathing patterns, and caregiver role strain. Quiet and comfortable environment was provided and necessary nursing procedures were executed to reduce patient's intracranial pressure. Progressive respiratory training was provided to facilitate maintenance of adequate oxygen level. Positive mental support was provided to empower family's efficacy of patient care and enable their emotional catharsis through using the principle of Ask- Tell-Ask. Information from decision making meetings were shared with family members. This report can serve as a reference for nursing staff to care patients who was first admitted in ICU with hemorrhage caused by intracranial aneurysm rupture.