照護一位頭部外傷青少年病患之護理經驗

本篇個案報告主要描述照護一位青少年個案因車禍造成頭部外傷，開顱手術後所面臨的問題。筆者於98年10月15日至11月23日期間，運用羅氏適應模式。經由實際觀察、參與照護及身體評估，將資料加以整理分析，發現個案於開顱手術後面臨有顏面神經受壓迫、術後傷口照護及身體心像改變等問題。在顏面神經受壓迫方面，筆者給予降低顱內壓之護理措施，避免血腫擴大增加壓迫而惡化病情。術後傷口照護，則給予避免感染並促進傷口癒合之照護措施。身體心像改變方面，著手進行評估分析個案所處的心理時期，協助其了解自我非理性之想法，導向正向之觀點看法，以及適時的給予澄清、反詰，並提供調適技巧及方法，准許個案適時自我隱藏，幫助個案增強自我信心，協助恢復日後出院之社交活動，藉此提昇護理服務品質，使個案能獲得連續性與整體性的照護。

關鍵字

頭部外傷；身體心像改變；羅氏適應模式

並列摘要

In this report, we describe our nursing experience caring for a teenager with a traumatic head injury from October 15th to November 23th in 2009. The injury, which was due to a traffic accident, was treated by craniotomy. Using Roy's Adaptation model, we monitored recovery by observation, caring and physical examination. After craniotomy, the medical and nursing problems were found to be facial nerve compression, postoperative wound caring and body image change. First, facial nerve compression was treated by lowering intracranial pressure in order to prevent other further combined symptoms. Second, postoperative wound was handled carefully to enhance wound healing and to prevent the occurrence of infection. Third, the patient's mental condition was evaluated and the patient was guided to help him come to a more realistic evaluation of his state and recovery in order to help him adopt a more positive view. The patient was treated by professional counseling, which included proper clarification or questions in response at the appropriate moment. The counseling allowed for proper self-hiding and helped the patient improve self-confidence and adaptive strategies to normal social communication. The experience and reflection on this case was recorded and discussed for the improvement of continuous and integral caring in general.

並列關鍵字

Head injury ； body image change ； Roy's Adaptation Model

國際替代計量

照護一位頭部外傷青少年病患之護理經驗

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