照顧一位顱內動脈瘤破裂個案之急診照護經驗

Nursing experience of a patient with intracranial aneurysm rupture in an emergency department

施名娟(Ming-Chuan Shih) ； 黃沛榆(Pai-Yu Huang)

《嘉基護理》 20卷2期 (2020/12) Pp. 40-47

摘要

本文為照護一位47歲男性，因顱內動脈瘤破裂透過微創栓塞手術預防再出血個案之急診護理經驗；過程中發現，案妻因突如其來的疾病以及後續治療不瞭解，而出現焦慮不安的情緒甚至影響後續醫療進行，故為本篇選案理由；照護期間為2017年9月26日10:13～13:00，選用Gordon十一項健康功能型態作為評估工具，發現問題：呼吸道清除功能失效、腦組織灌流改變、焦慮等；給予護理措施，包括：監測生命徵象，維持呼吸道暢通，預防顱內壓升高與觀察有無顱內壓增高徵象，過程中案妻一度情緒失控無法做任何決定，則運用醫病共享原則，透過輔助工具並加上口頭講解以及提供相關研究數據進行說明，並將照護原則與加護病房主責護師交班，個案於10/22順利出院，持續於門診復健中；藉由此護理經驗可提供日後照護此類個案之參考。

關鍵字

顱內動脈瘤破裂 ； 急診照護 ； 呼吸道清除功能失效 ； 腦組織灌流改變 ； 焦慮

並列摘要

This article describes the nursing experience of a 47-year-old male patient who was sent to the emergency room for a ruptured intracranial aneurysm and later received a minimal invasive embolization surgery to prevent rebleeding. During the process, the patient's wife demonstrated strong anxiety due to her lack of understanding about her husband's disease, and even affected the following medical treatment. Therefore, the case was chosen for this article. During 10:13-13:00 on September 26th, 2017, Gordon's 11 functional health patterns were applied together with measures such as physical evaluation, direct attendance, indirect observation, and communication to collect data about the patient. According to the collected data, the patient was found to have nursing problems such as respiratory failure, altered brain tissue reperfusion, anxiety and other nursing problems. The author first addressed the urgent nursing problems of the patient. The patient was given nursing measures such as monitoring of vital sign changes, maintaining clear airways, preventing higher intracranial pressure, continuous ICP observation, and preoperative preparation. The wife could not make any decision as she was out of control. Therefore, the team members helped her to understand more about the disease and surgery by showing her a video introducing the surgery and providing her with oral explanation and related research data. The ICU nurses in charge of taking care of the patient were also instructed with nursing principles. After the successful completion of the surgery, the patient was discharged on October 22nd and received continuous outpatient rehabilitation care. The nursing experience in this case provides references to similar cases in clinical practice.

並列關鍵字

Intracranial aneurysm rupture ； emergency care ； failure of respiratory clearing function ； changes in brain tissue perfusion ； anxiety

參考文獻

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