運用ABCDEF組合式照護措施改善創傷性腦損傷病人譫妄之護理經驗

Experience of Implementing ABCDEF Bundle Care to Reduce Delirium in a Traumatic Brain Injury Patient

10.6224/JN.202010_67(5).12

簡孟萱(Meng-Hsuan CHIEN)；梁鈞瑜(Chung-Yu LIANG)；高啟雯(Chi-Wen KAO)

組合式照護 ； 創傷性腦損傷 ； 譫妄 ； bundle care ； traumatic brain injury ； delirium

護理雜誌

67卷5期（2020 / 10 / 01）

89 - 98

繁體中文

創傷性腦損傷病人譫妄發生率極高，並會導致不良預後，本文描述運用ABCDEF組合式照護措施改善創傷性腦損傷個案急性譫妄情形之護理經驗。護理期間為2019年4月23日至2019年4月30日，運用會談、觀察、身體評估及病歷查閱等方式進行生理、心理、家庭及社會、靈性等層面之全面性護理評估，確立個案具有急性譫妄、腦部組織灌流失效等健康問題，且個案因面臨家庭困境而延伸出照顧者角色緊張問題。護理期間依照個案之個別性，運用ABCDEF組合式照護執行自發覺醒測試、自發呼吸測試、協調照護整合、譫妄評估、早期活動、家屬參與等多重措施，協助降低譫妄，並同時藉家屬參與過程以及與社工跨領域合作方式降低經濟與照護負擔，改善照顧者角色緊張問題。期望藉此護理經驗，提高臨床照護對於創傷性腦損傷病人譫妄的早期發現與重視，並由不同面向切入，提供組合式護理措施，發揮護理的全人照護精神。

Patients with traumatic brain injury (TBI) have a high incidence rate of delirium, which leads to poor prognoses. This case study describes a nursing experience of implementing ABCDEF bundle care to reduce delirium in a patient with TBI. The period of nursing care was April 23 to April 30, 2019. A comprehensive assessment of this patient's physical, psychological, familial, social, and spiritual dimensions was conducted via consultation, observation, and physical assessment. The assessment results showed that the patient suffered from acute delirium and cerebral perfusion impairment. In addition, the results showed that the patient's wife suffered from caregiver role strain that was further exacerbated by family difficulties. Multiple, individualized patient-tailored nursing interventions were developed under ABCDEF bundle care to alleviate delirium during the period of nursing care. These interventions included spontaneous awakening trials, spontaneous breathing trials, coordination, delirium assessment, early mobilization, and family engagement. Furthermore, family involvement and interprofessional cooperation with social workers were conducted concurrently to alleviate economic and care burdens and mitigate caregiver role strain in the patient's wife. It is hoped that this nursing care experience helps promote increased attention towards delirium, helps improve early detection of delirium in patients with TBI, and promotes the provision of individualized bundle care that draws on different perspectives in order to achieve holistic health care.

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