本文旨在照顧一位男性腦瘤術後個案的護理經驗,護理期間2019年11月4日至12月4日,藉由直接照護、觀察、會談及身體評估等技巧以Gordon十一項功能性健康型態,確立排尿型態改變、焦慮及照顧者角色緊張等健康問題。透過整合性醫療團隊間合作,依醫囑給予膀胱訓練,給予衛教並配合藥物治療,以成功移除導尿管;職能治療時增加個案擅長之繪畫以訓練手部功能,視狀況調整呼吸訓練,幫助個案盡早拔除氣切管;結合心理師及宗教介入,給予關懷、傾聽以降低個案對未來不確定的焦慮,藉由示教及回示教幫助照顧者能主動參與照顧個案,促使個案早日回歸家庭;期望藉此個案照護經驗分享,提供臨床照護之參考。
This case study aims to report the nursing experience of a male brain tumor postoperative case, and the nursing period was from November 4 to December 4 in 2019. Through techniques such as direct care, observations, conversations and physical assessments for data collection; by applying Gordon11 Functional Health Patterns to establish health problems such as changes in urination patterns, anxiety, tension in caregiver roles and so on. Through cooperation between integrated medical teams, bladder training is given according to the doctor's advice, health education is offered and drug treatment is provided to remove the urinary catheter successfully. During occupational therapy, add drawing session that the patient is good at for hand functional training, adjust the breathing training according to the situation, and assist the patient remove the tracheostomy tube as soon as possible. Incorporate psychologists and religious intervention to provide care, listen to the case to reduce his anxiety regarding uncertainty in the future. Through teaching and responding, assist caregivers to initiate caring for the case, and prompted the patient to return back to family life. It is hoped that this care experience sharing will provide a reference to clinical care.