照顧一位年輕婦女頭部外傷術後之護理經驗

Postoperative Nursing Experience of Caring for a Young Woman with a head Injury

本文描述一位35歲婦女因車禍意外導致頭部外傷術後之護理經驗。照護期間為2020年9月8日至9月28日，藉由實際照護、會談、觀察、傾聽、身體檢查及電話訪談方式收集資料，使用整體性護理評估進行生理、心理、社會及靈性等層面對個案進行資料收集，確立主要問題有身體活動功能障礙、焦慮、身體心像紊亂等護理問題，拒絕復健治療，影響復原的黃金時機。運用跨領域團隊合作照護，包含復健師、社工師、心理師與出院準備護理師等共同協助，提供專業技能，漸進式引導病人接受復健治療，增強連續性復健的重要認知，連結病友經驗的分享，減輕個案對疾病預後的焦慮、不安，藉由心理治療師的專業諮商、放鬆技巧等，改善初期因身體心像改變與焦慮拒絕復健治療的問題，共同鼓勵個案及家屬參與制定復健計畫，會同出院準備照護協助申請輔具等長照資源，增強正向意願，強化身體活動功能，重拾自信，出院後轉復健醫院進行連續性照護。建議臨床可多運用跨領域專業會議，了解彼此的專業角色與功能，共識後整合個案的主要問題與照護方案，提供最適合與個別性的完整照護，藉此護理經驗，期盼能提供臨床照護之參考。

This article described the postoperative nursing experience of caring for a young woman with a head injury caused by a car accident. Care was provided from Sep 8th to Sep 28th, 2020. Data were collected through actual nursing care, case interviews, observations, listening, physical examinations, and telephone interviews. We collected the patient's physical, psychological, social, and spiritual functioning data. Further, we adopted a comprehensive nursing assessment to determine the nursing-related problems of the patient, including physical dysfunction, anxiety, and body image disturbance that led to the refusal of rehabilitation treatment and affected the golden opportunity for recovery. We employed interprofessional collaborative care with the joint assistance of rehabilitators, social workers, psychologists, and discharge planning nurses to provide professional skills to guide the patient to gradually receive rehabilitation treatment and enhance the awareness of the importance of continuous rehabilitation. The experience shared by patients with similar conditions were combined to alleviate the anxiety and discomfort of the patient regarding the disease prognosis. The refusal of rehabilitation treatment due to body image disturbance and anxiety during the early stage was reduced through the professional consultation and relaxation skills provided by psychotherapists. Moreover, the patient and her family members were encouraged to participate in the formulation of rehabilitation plans. The discharge planning nurse also assisted in applying for long-term care resources such as assistive devices to enhance a positive attitude, improve physical activity skills, and regain self-confidence. The patient was referred to a rehabilitation hospital to receive continuous care after discharge. We recommend interdisciplinary professional meetings used in clinical practice to understand the professional roles and functions of the participants, and integrate the main problems and care plans of the case by consensus to provide the most appropriate and individualized comprehensive care for the patient. We wish to share this nursing experience for reference in clinical practice.