照顧一位初次腦梗塞病人急性期之加護護理經驗

Nursing Care Experience in Intensive Care Unit for Patient with First-ever Cerebral Infarction

林鳳君(Feng-Chen Lin)

《臺大護理雜誌》 15卷1期 (2019/01) Pp. 100-110

https://doi.org/10.6740/NTUHJN.201901_15(1).0010

摘要

本文描述一位初次腦中風中年男性之急性期加護護理經驗，個案因腦梗塞使腦血流灌注不足，予靜脈血栓溶解劑，症狀曾獲改善，但後續合併嚴重腦疝脫，危及個案生命。於2016年5月22日至6月8日，運用Gordon 11項功能性健康型態評估，經由觀察、會談、直接照護等方式，確立個案主要有腦組織灌流失效、身體活動功能障礙、呼吸道清除功能失效、個人因應能力失調等健康問題。護理措施包括密切評估病人的神經學和生命徵象的變化，以維持理想之腦部灌流，降低急性腦中風之併發症；面對嚴重的腦中風使肢體癱瘓及自咳能力降低，協助進行胸腔物理治療，如姿位引流、背部扣擊和抽痰等護理措施；醫療團隊共同協助個案採漸進式脫離呼吸器及維持關節活動度；護理指導家屬參與個案之照顧，耐心溝通及同理個案感受，使其有動機參與治療。建議於此類病人趨於穩定時，可提供社會支持團體資訊，以增加病人和家屬們的因應能力。

關鍵字

腦梗塞 ； 腦疝脫 ； 腦組織灌流失效

並列摘要

In this article, we discussed our experience in critical care nursing for a middle-aged man during the acute stage of his first-ever stroke. In our patient, cerebral hypoperfusion caused by cerebral infarction was treated with thrombolytic therapy. His condition once improved, but eventually progressed, causing complication of cerebral herniation which resulted in the death of the patient. We use Gordon's 11 functional health patterns' assessment, through observation, interview, and direct care etc., to identify the health problems including ineffective cerebral tissue perfusion, impaired physical mobility, ineffective airway clearance, and impaired individual coping etc. During the critical care nursing from May 22 to June 8, 2016. With close evaluation of the changes in the neurological status and vital signs, we maintained the brain perfusion of our patient and thus reduced the complications. Severe stroke could cause limbs paralysis and reduction in sputum clearance. Thus, we provided chest physical therapy such as position changes, chest percussion, and sputum suction. We with the medical team help in progressive weaning from mechanical ventilation and maintaining range of joint motion. Being patient in communication and showing empathy to our patients facilitate the coordination between family members, so that our patients are motivated to participate in treatment. When the disease stabilizes, we can provide social support group information and increase the coping abilities of our patients and their families.

並列關鍵字

cerebral infarction ； brain herniation ； ineffective cerebral tissue perfusion