本文描述一位創傷性顱內出血個案術後於加護病房照護的經驗,於2017年2月6日至19日透過身體評估、觀察、會談等方法收集資料,進行生、心、靈、社會之整體性評估,發現個案有腦組織灌流改變、身體活動功能障礙、焦慮之健康問題。在照護過程中,提供個別性護理措施,維持生命徵象穩定,沒有顱內壓升高之徵象;對於疾病導致的身體活動功能障礙,以及肢體偏癱產生的焦慮情緒,運用Swanson理論了解個案之想法及需求,協助其面對疾病帶來的衝擊,緩解其焦慮的情緒,引導正向情緒發展,鼓勵積極參與復健計畫,早日恢復原有之生活。建議未來除了生理層面評估外,可透過家庭支持系統和跨團隊領域合作協助類似個案儘早參與復健活動,早日恢復原有生活軌道。
This report describes the nursing experience and care of a traumatic intracranial hemorrhage patient after surgical treatment in ICU. The authors collected data through physical assessment, observation, and interview from February 6th to 19th, 2017. A comprehensive assessment of the patient's physiological, psychological, social and spiritual states was noted and used to identify health concerns including ineffective cerebral tissue perfusion, physical activity dysfunction, and anxiety. During the nursing period, individual nursing care was provided to maintain a normal range of vital signs and intracranial pressure. Utilizing Swanson's theory, the authors assisted the patient in adjusting to the impacts of impaired physical mobility and hemiplegia according to his feelings and needs, and then relieved his anxiety. The authors led the case to improve positive attitude development and encouraged him to take an active participation in the rehabilitation treatments. The study suggests that the cooperation between family support and multi-medical teams can help similar cases to participate in rehabilitation treatments, besides developing the physiological aspect assessment and thus recovering a normal life as soon as possible.
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