照顧一位腦動靜脈畸形青少年接受開顱手術之重症護理經驗

Nursing Care Experience for an Arteriovenous Malformation Adolescent Patient Received Craniotomy during Intensive Care

邱盈熒(Ying-Ying Chiu) ； 陳香蘭(Hsiang-Lan Chen) ； 陳淑卿(Shu-Ching Chen)

《馬偕護理雜誌》 8卷2期 (2014/07) Pp. 61-72

https://doi.org/10.29415/JMKN.201407_8(2).0006

摘要

本文是探討一位13歲病童因腦部動靜脈畸形接受開顱手術後的重症護理經驗，筆者在2012年4月16日至4月20日期間，藉由直接照護、觀察、身體評估及治療性會談等方式進行資料收集，運用Gordon十一項功能性健康型態作為評估指引，發現個案有潛在危險性肺吸入、顱內壓調適能力降低、及身體心像紊亂等問題，護理過程中採側臥及抬高床頭姿勢，無吸入嘔吐物情形；維持氧合與適當體溫，無出現顱內壓升高症狀；正向鼓勵及支持個案正視外觀的改變，個案能表達對身體心像改變的正向看法，期望能經由此護理經驗分享，提供護理人員照護的參考。

關鍵字

腦動靜脈畸形 ； 開顱手術 ； 重症護理

並列摘要

This case reported the intensive care nursing experience of a thirteen adolescent with arteriovenous malformation received craniotomy. The caring period was from April 16, 2012 to 20, 2011. The Gordon's functional health assessment guide was used to assess nursing problem through direct care, observation, physical examination and interview. The nursing problems being identified included risk for aspiration, intracranial adaptive capacity, decreased, and disturbance body image. Nursing care process in order to prevent vomit, the patient must be lateral decubitus position and the head of bed high. Maintain oxygenation and normal body temperature to avoid symptom of increased intracranial pressure. Positive encourage and support to appearance change, and patient could positively express on body image concern. This experience provided nurses with a reference for caring similar patients in the future.

並列關鍵字

Arteriovenous Malformation ； Craniotomy ； Intensive Care