照護一位顱內動脈瘤破裂術後脫離呼吸器個案之護理經驗

Nursing Experience with A Patient Weaned from A Ventilator after Surgery for A Ruptured Intracranial Aneurysm

本文係照護一位顱內動脈瘤破裂術後個案，面臨死亡率極高的動脈瘤再次破裂之情境，進行脫離呼吸器之護理經驗。護理期間為2012年6月29日至2012年7月17日，筆者藉由直接照護、身體評估、與家屬會談及觀察等方式收集資料，依Gordon十一項健康功能型態進行整體性評估，結果發現個案有顱內調適能力降低、呼吸機戒斷反應功能失常、照顧者角色緊張等護理問題。在照護期間，筆者除了依呼吸器脫離之流程執行護理計畫，並在進行脫離呼吸器過程中，持續監測生命徵象與意識變化，儘量減少Valsalva相關活動，以避免顱內壓升高，再藉由漸進式脫離呼吸器，以降低個案再度出血之風險。另外，因家屬擔心隨時可能再次破裂出血，不敢接觸個案，產生照顧者角色緊張，因此筆者與家屬討論後續照護之計畫，以增進其自我照顧能力，進而協助漸進式訓練讓個案成功脫離呼吸器，轉至一般病房。針對此類個案建議呼吸照護中心未來可以提供彈性會客方式，及早照會臨床心理師評估其需求，讓家屬發展因應措施，以避免動脈瘤再次破裂死亡之心理衝擊。

This is a report of nursing experience in caring for an seventy-one-year-old woman who had suffered from a ruptured intracranial aneurysm, which is highly fatal if it reoccurs, and was being weaned from a ventilator. The author collected data during the nursing period from June 19, 2012 to July 17, 2012, by means of direct care, physical evaluation, discussion with family members, and observation. Based on Gordon's 11 functional health patterns, the patient had decreased intracranial adaptation and anomalous responses to being weaned from the ventilator, and there was also caregiver role strain. In the nursing period, the author not only followed the procedure for weaning from the ventilator, but also monitored the patient's level of consciousness and vital signs, In order to avoid rising intracranial pressure, the patient was encouraged not to perform Valsalva-related activities. Step-by-step weaning from the ventilator reduced the risk of reoccurrence of bleeding. Because the patient's family members were afraid of another bleeding episode, they kept their distance from the patient, resulting in caregiver role strain. The author discussed with them on the need to encourage the patient to take care of herself, and to be weaned from the ventilator. The patient was then transferred to a general ward. This study suggested that a Respiratory Care Center should provide flexible visiting regulations when dealing with similar cases and family members should consult with a clinical psychologist about the patient's condition. If the family members understand the scenario, then there may be less mental impact if the patient should die as a result of reoccurrence of the ruptured intracranial aneurysm.