一位腦出血術後個案於急性後期照護之護理經驗

Nursing experience in the post-acute care of a patient after an intracerebral hemorrhage

本文描述一位58歲女性診斷為左側基底核出血進行顱骨切開術術後病況穩定之個案，經急性後期整合照護團隊評估後，轉介本院接受後續復健治療計畫。照護期間於2019 年2 月22 日至2019 年03月26日間。筆者以直接照護、會談、傾聽、身體評估及查閱病歷等方式收集資料，並運用Gordon十一項健康功能型態為評估架構，歸納分析個案護理問題有吞嚥障礙、自我照護能力缺失及焦慮等。個案於住院間，以跨領域團隊合作照護模式進行吞嚥訓練，以避免吸入性肺炎之併發症，同時評估與維持個案每日營養所需，以預防營養失調；規律地進行復健治療，以促進個案的活動功能；期間筆者透過主動關懷來建立相互信賴的治療關係，以傾聽、有效溝通，鼓勵個案表達其感受，給予傾聽與協助，且提供相關社福資源，以減輕個案之焦慮感。筆者期望藉此經驗，提供護理人員照護類似個案的參考。

This article described the nursing experience of caring a 58-year-old female patient with a left basal ganglia hemorrhage. After undergoing a craniotomy, the patient was evaluated by an integrated postacute care team. She was found to be in stable condition and referred to the hospital for rehabilitation. The nursing care period was from February 22 to March 26, 2019. During this time, Gordon's Eleven Functional Health Patterns framework was used for assessment and data analysis. Data were collected through direct care, interviews, active listening, physical assessment, and analysis of medical records. The patient was found to have dysphagia, self-care deficit, and anxiety. In an effort to prevent aspiration pneumonia during hospitalization, the patient received swallowing training by an interdisciplinary team. To prevent nutritional imbalances, a nutritional assessment was overseen and the patient’s daily nutritional needs were met. The patient also received regular rehabilitation to increase mobility. Additionally, the patient’s anxiety was alleviated by establishing a mutually-trusting therapeutic relationship through active care and listening, effective communication, encouraging her to express her feelings, counseling, and by providing relevant social welfare resources. We hope nursing professionals dealing with similar situations may benefit from the publication of this experience.