運用R-L-T護理模式照護一位頭部創傷病人的護理經驗

Experience of Using the Roper-Logan-Tierney model of Nursing on a Traumatic Brain Injury Patient

張大容(Ta-Jung Chang) ； 陳玉如(Yu-Ju Chen) ； 楊嘉禎(Chia-Chen Yang)

《高雄護理雜誌》 37卷3期 (2020/12) Pp. 58-67

https://doi.org/10.6692/KJN.202012_37(3).0006

摘要

本文描述照護一位50歲女性因騎乘單車自摔導致急性硬腦膜下腔出血，於加護病房期間，提供密切監測及積極治療以減輕續發性腦損傷及改善預後之護理過程。護理期間自2016年05月07日至2016年05月19日，以直接照護、會談、觀察及查閱病歷等方式進行資料收集，並運用R-L-T護理模式進行評估，確立健康問題為腦組織灌流改變、呼吸道清除功能失效及睡眠型態紊亂。急性照護期間，為維持正常腦灌注壓，密切觀測顱內壓及平均動脈壓變化及意識改變，以避免二次傷害發生。此外，透過提供適當氧合與換氣功能、採集中護理安排合宜休息活動時間、減少環境刺激等，使個案降低生心的不適感，提供一個高品質的護理照護。

關鍵字

頭部創傷 ； R-L-T護理模式

並列摘要

This article discusses a 50-year-old female suffering from acute subdural hemorrhage from a bicycle accident. Intensive monitoring and aggressive treatment were implemented to alleviate the patient's secondary brain injury and improve her prognosis in ICU from May 7 to May 19, 2016. We collected information via direct patient caring, conversation, observation and medical chart reviewing for this patient, while the R-L-T (Roper, Logan and Tierney) nursing model was applied to assess the patient's health problems. Ineffective tissue perfusion - cerebral, ineffective airway clearance and disturbed sleeping pattern were two diagnosed nursing problems. To maintain sufficient cerebral perfusion pressure, intracranial pressure and mean arterial pressure were intensively monitored and corrected to prevent secondary damage. By maintaining sufficient oxygenation and ventilation, scheduling adequate rest and activity by cluster clinical care, and decreasing environmental stimuli to reduce physical and psychological discomfort, quality of care was facilitated.

並列關鍵字

Traumatic brain injury ； Roper, Logan and Tierney model of nursing

參考文獻

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