協助一位年輕型腦中風個案之加護經驗

An Intensive Nursing Experience of assisting for a Young Stroke Patient

本文探討一位正值具備生產力、為社會奉獻之年輕男性，因發生腦梗塞導致腦水腫並引發顱內高壓，行開顱減壓手術之加護照護經驗。於2018年5月12日至5月30日照護期間，運用Golden 11項功能性健康評估，藉由會談、傾聽、觀察等方式收集資料，確立有呼吸道清除功能失效、顱內調適能力降低、身體活動功能障礙、無望感之健康問題。照護過程藉由提供胸腔照護、協助抽痰，以維持呼吸道通暢，並逐步行呼吸訓練以脫離呼吸器；密切觀察神經學狀態以預防續發性腦損傷；及早評估介入物理治療，同時鼓勵家屬一同參與復健過程，以提升病人復健動機；以真誠的態度關懷個案、建立良好的護病關係，主動提供相關資訊以減少其不確定感、減輕無望感，重建正向態度來面對疾病及未來的日子，順利回歸社會。期藉此案例提供臨床同仁作為照護此類個案之參考依據。

This article describes an intensive nursing experience when assisting a young man who was contributing to society, but suffered intracranial hypertension from brain edema caused by cerebral infarction, and had to undergo craniotomy and decompression. During the period from May 12 to May 30, 2018, Gordon 11 Function Health Patterns were used to collect data through interviews, listening, observation, etc., the following main problems in nursing were identified: ineffective airway clearance, decreased intracranial adaptive capacity, and impaired physical mobility and hopelessness. The nursing process provided chest care and sputum suction assistance to keep respiratory tract unobstructed, and the breathing training was gradually performed to get out of the respirator. Through the close observation of neurological conditions to prevent recurrent brain damage, the intervention physiotherapy could be evaluated as early as possible, and his family members were also encouraged to participate in the rehabilitation process. Use a sincere attitude to care to the case and establish a good nurse-patient relationship, actively provide the disease-related information to reduce their sense of uncertainty and hopelessness, rebuild a positive attitude to face the disease and the future, smooth return to society. This case provides a reference for clinical colleagues in the treatment of such cases.