照護一位創傷性腦損傷個案之護理經驗

本文描述一位17歲男性創傷性腦損傷之個案，經手術治療後有氣切管留置及左側肢體偏癱問題，需持續住院治療復健，面對突發意外，個案因無法接受身體外觀的改變，感到情緒低落與缺乏自信，護理期間自2019年4月24日至2019年5月20日，運用觀察、筆談及參與直接照護，以Gordon十一項健康功能評估工具進行評估，確認個案住院期間所呈現的健康問題為『呼吸道清除功能失效』、『身體活動功能障礙』、『身體心像紊亂』；照護過程中，與個案及照顧者建立信賴的治療性關係，擬定脫離氣切管計劃，加強呼吸肌訓練，減少痰液蓄積，增加肺部擴張，成功移除氣切管；進而針對肢體障礙給予疾病相關知識及適當復健運動，避免肢體攣縮，增加肌力與平衡，提升肢體最大功能；運用傾聽及同理，鼓勵個案正視外觀的改變、引導說出自己內心的感受，幫助個案接受身體改變所帶來的衝擊。期望透過此個案護理經驗的分享，作為日後照護此類個案之參考，使護理人員之角色功能得以揮發。

關鍵字

創傷性腦損傷；身體心像紊亂；呼吸道清除失效

並列摘要

This article describes a 17-year-old man with traumatic brain injury. After surgical treatments were tracheotomy and left hemiplegia problems. Facing unexpected accidents, the case was unable to accept changes in the appearance of the body, feeling depressed and lacking self-confidence. During the nursing period from April 24, 2019, to May 20, 2019, we used Gordon's eleven health function assessment tools to evaluate the patient's health problems by using observation, written interviews and direct care. It is confirmed that the health problems are ＂Impaired physical mobility＂, ＂Ineffective airway clearance＂, ＂Body image disturbance＂. During the care process, we established a trusted therapeutic relationship with plan to remove tracheostomy, while strengthening respiratory muscle training to reduce sputum, increase lung expansion, and finally successfully remove tracheostomy. Using listening and empathy, we guided the case to face the change of appearance, express inner feelings, accept the impact of physical changes and actively face the problem. We worked with the medical team to develop a rehabilitation program that provided individual care guidance to strengthen his self-care ability, enhance muscle strength and balance, avoid limb contracture and enhance the maximum function of the limb. Use listening and empathy to encourage individuals to face up to changes in appearance, express inner feelings and help individuals to accept the impact of physical changes. It is hoped that the sharing of nursing experience will serve as a reference for taking care of such cases in the future, so that the role function of the nursing can be volatile.

並列關鍵字

traumatic brain injury ； body image disturbance ； Ineffective airway clearance

參考文獻

江家貞、蔡函真、王淑珍、呂佩珍、范君瑜、郭素娥（2014）‧提升創傷性腦損傷開顱術後病人翻身擺位之正確率‧馬偕護理雜誌，8（2）， 26-37。[Jiang, J. Z., Tsai, H. C., Wang, S. C., Lu, P. C., Fan, J. Y., & Guo, S. E. (2014). Elevating theaccuracy rate of postural change in patient with traumaticbrain injury after craniotomy. Journal of MacKay Nursing, 8(2), 26-37.] doi:10.29415/JMKN.201407_8(2).0003

林欣怡、方美玲、孫美華（2014）‧以歐倫自我照顧理論照護一位獨居腦中風患者之護理經驗‧ 長庚科技學刊，（20），119-130。[Lin, H. Y., Fang, M. L., & Sun, M. H. (2014). Nursing experi- ence in applying Orem’s theory to a strokepatient living alone. Chang Gung Journal of Sciences, (20), 119-130.] doi:10.6192/CGUST.2014.6.20.13

邱盈熒、陳香蘭、陳淑卿（2014）‧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‧馬偕護理雜誌，8（2），61-72。[Chiu, Y. Y., Chen, H. L., & Chen, S. C. (2014). Nursing care experience for an arteriovenous malformationadolescent patient received craniotomy during intensive care. Journal of MacKay Nursing, 8(2), 61-72.] doi:10.29415/JMKN.201407_8(2).0006

陳冠宇、林琪馨（2016）‧一位插管導致聲帶麻痺行氣切管手術後病人之護理經驗‧新臺北護理期刊，18（2），95-105。[Chen, G. Y., & Lin, C. H. (2016). The nursing experience of a patient follow- ing a tracheostomy for treating vocal cordparalysis caused by intubation. New Taipei Journal of Nursing, 18(2), 95-105.] doi:10.6540/NTJN.2016.2.009

陳慧秦、王秀紅（2014）‧氣切照護管理運用在呼吸器依賴病人的文獻評析‧長庚科技學刊，（21），25-38。[Chen, H.C., & Wang H. H., (2014). The management and utilization of tracheos- tomy care for ventilator dependent patients a literature review. Chang Gung Journal of Science, (21), 25-38.] doi:10.6192/CGUST.2014.12.21.3

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