照顧顱內動脈瘤破裂病人之加護經驗

Intensive Nursing Care Experience of a Patient with Ruptured Aneurysm

熊梅鳳(Mei-Feng Hsiung)；黃惠美(Hui-Mei Huang)

顱內動脈瘤 ； 加護照護 ； intracranial aneurysm ； intensive care unit

榮總護理

27卷3期（2010 / 09 / 01）

314 - 319

繁體中文

本文是探討一位60歲罹患顱內動脈瘤破裂接受開顱手術且術後出現水腦併發症之病人，自2008年12月14日至2009年1月7日在加護病房護理經驗。藉由會談、觀察、身體評估，配合羅氏適應模式概念架構進行護理評估，個案需優先處理呼吸道清除功能失效、潛在危險性損傷及身體活動功能障礙等三個健康問題。筆者在病人狀況不穩定時，依動脈瘤破裂開顱術後的3H原則提供照護：維持高血壓、高血容積及稀釋血液，預防併發症的發生，並成功協助病人脫離呼吸器；對於家屬方面藉由傾聽及同理心建立治療性人際關係，鼓勵參與護理活動及協助轉換緊張的情緒。藉此分享個人之護理經驗，期望有助於提升此類病人的照護品質。

This is a case report of a 60-year patient with ruptured aneurysm, complicated by diffuse subarachnoid hemorrhage (SAH) and hydrocephalus. We shared the nursing experience during December 14th, 2008 to January 7th, 2009. Using Roy Adaptation model, nursing evaluation was completed via interview, observation, and physical evaluation. The three main health problems were ineffective airway clearance, risk for infection, and impaired bed mobility. During the acute stage, the nursing policy followed the triple-H therapy: Hypertensive, Hypervolemic, and Hemodilution. The patient was then weaned from mechanical ventilator. To the patient's family, we encouraged them to listen with empathy so as to develop therapeutic interpersonal relationship with the patient. Also we encouraged the family to participate in the nursing care in order to reduce anxiety. Nurses played a vital role in the care system. This case report can not only improve the nursing care but also help in promoting nursing care quality.