照顧一位車禍導致頭部創傷引發蜘蛛膜下腔出血個案之加護護理經驗

The ICU Nursing Experience of Caring for a Patient with Head Trauma and Subarachnoid Hemorrhage Caused by a Traffic Accident

本篇報告乃描述因車禍導致頭部創傷引發蜘蛛膜下腔出血並裝置腦室外引流、全身多處撕裂傷及擦傷個案之護理經驗。護理期間於2009年11月12日到2009年11月14日，筆者藉由直接照護、紙筆會談、觀察等方式收集資料，依Gordon十一項功能性健康型態進行評估。確立個案四個主要護理問題有：潛在危險性感染、顱內調適能力降低、組織完整性受損、焦慮。照護期間，筆者注意到個案因腦部遭受創傷伴隨多處皮膚損傷，教導個案照護傷口方法，預防感染，密切觀察導管周圍皮膚，因顱內調適能力降低引發頭痛、頭暈、噁心，監測顱內壓及平均動脈血壓以維持腦血液灌流量，預防二度腦傷害的發生。筆者發現個案頭部創傷後擔心預後及後遺症影響之後工作而產生焦慮，藉由雙方護病關係建立，使個案明瞭疾病發展及治療過程，透過持續關懷、傾聽、同理，進而使個案能適時表達內心想法，逐漸減輕焦慮，促使病患穩定地恢復。希望藉此護理經驗的分享提供臨床護理同仁的照護之參考。

This report describes the care of a patient who had head trauma with subarachnoid hemorrhage caused by a traffic accident. ICU nursing included the care of ventricular drainage devices and multiple lacerations and abrasions. During the period of nursing care from November 12, 2009 to November 14, 2009, we assessed the patient according to Gordon s11 functional health assessments. We collected information by applying the nursing skills of observation and conversation, then recorded the information in writing. The four nursing problems we found were the potential risk of infection, reduced intracranial adaptive capacity, impaired tissue integrity, and anxiety. In practice, we paid attention to wound care, educated the patient, prevented infection, observed the skin around the wound, evaluated the headache, dizziness and nausea that resulted from reduced intracranial adaptive capacity, and monitored ICP and MAP closely to prevent secondary brain injury by maintaining adequate cerebral blood perfusion. The patient was anxious because he worried about losing his job and not knowing how severe the sequelae would be. After a good relationship between nurse and patient was established, the patient understood the course of the injury and the process of treatment. Empathic listening enabled the patient to express his misgivings and this will be helpful in his recovery.