顱內出血病人術後成功脫離呼吸器之護理經驗

Nursing Care Experience of Ventilator Weaning for a Patient with Intracerebral Hemorrhaging after Surgery

10.6142/VGHN.31.2.158

黎沛姍(Pei-Shan Li)；鄒茵茵(Yin-Yin Tsou)

顱內出血 ； 脫離呼吸器 ； 護理經驗 ； intracranial hemorrhage ； ventilator weaning ； nursing experience

榮總護理

31卷2期（2014 / 06 / 01）

158 - 164

繁體中文

本文敘述一位因腦血管疾病導致顱內出血，而施行開顱手術病人術後成功脫離呼吸器之護理經驗。護理期間自2011年12月19日至2012年1月5日，運用Gordon十一項功能性健康評估系統為評估架構，以觀察、會談、生理評估、語言溝通、實際照護及查閱病歷等方式收集資料作整體性評估，確立低效性呼吸型態、無力感、自我照顧能力不足、身體活動功能障礙等健康問題。腦血管疾病病人術後常因肢體活動障礙同時無法脫離呼吸器，導致身、心、靈方面諸多影響，在護理過程中藉由建立信任感及治療性關係，運用專業知識、技巧及醫療團隊合作照護，協助控制活動功能障礙，提供個別性、整體性及連續性護理，共同努力改善呼吸型態及成功脫離呼吸器，順利出院返家。

This article describes the nursing experience of a patient who was successfully weaned from a ventilator postoperatively after a craniotomy for cerebral vascular disease caused by intracranial hemorrhaging. The interval of treatment spanned from December 19, 2011 to January 5, 2012. To assess the health problems, such as ineffective breathing patterns, powerlessness, self-care deficit, and impaired physical mobility, we established a database through observation, interviews, physical examination, communication, bedside care, and the medical records, using the Gordon 11-item functional health assessment system to assess the framework. Cerebrovascular disease patients often experience inability to move limbs and difficulty weaning, which causes a substantial impact on the body, mind and spirit. Nursing care involves creating a sense of mutual trust and a therapeutic relationship, using professional knowledge and skills, organizing systemic care to limit activity dysfunction, and providing individualized, integral and continuous care to improve breathing performance and successfully wean patients from ventilators to achieve an early discharge.