照護一位顱內出血後腦積水病人之護理經驗

Nursing Experience of Caring a Hydrocephalus Patient after Intracranial Hemorrhage

10.6386/CGN.202112_32(4).0008

李宜靜(Yi-Jing Lee)；張乃文(Nai-Wen Chang)；王桂芸(Kwua-Yun Wang)

顱內出血 ； 創傷後腦積水 ； 護理經驗 ； intracranial hemorrhage ； post-traumatic hydrocephalus ； nursing experience

長庚護理

32卷4期（2021 / 12 / 01）

86 - 96

繁體中文

本文描述照顧一位顱內出血後腦積水之病人，護理期間為2019年4月10－18日，藉由Gordon十一項功能性健康型態為評估工具進行資料收集與分析，確立病人主要健康問題有：吞嚥功能障礙、身體活動功能障礙、顱內調適能力降低。照護期間針對吞嚥功能障礙提供家屬與主要照顧者協助病人進食與喝水技巧，以減少病人發生嗆咳情形，避免因吞嚥困難之合併症發生。並協助指導家屬與主要照顧者能協助病人翻身擺位與被動式關節活動，與醫療團隊訂定病人復健計畫，協助下床使用高背輪椅。針對顱內調適能力降低，密切監測及處置神經學變化。於執行護理措施後，家屬與主要照顧者能以安全的方式，協助病人進食後無出現嗆咳、吸入性肺炎徵象、體重減輕、營養不良等合併症狀且無肌肉攣縮或僵硬情形。照護期間病人亦無發生意識變化、神經學異常或顱內壓升高徵象。期望此護理經驗可作為護理人員在照護顱內出血後腦積水病人時之參考，以提升護理人員照護品質。

This article described the experience of caring a patient with post-traumatic hydrocephalus after intracranial hemorrhage. During the care of period from April 10 to 18, we found that the patient had health problems including impaired swallowing, impaired physical mobility, and decreased intracranial adaptive capacity using Gorden's 11 functional health patterns assessments. In terms of impaired swallowing, the author instructed the caregiver using eating and drinking strategy to decrease choking. In addition, the author instructed primary caregiver to help the patient perform a range of motion exercises and make a rehabilitation plan for helping patient get out of the bed by using high back wheelchair with medical team. The author closely monitored consciousness of the patient and neurological status for decreased intracranial adaptive capacity. Because of nursing intervention, provided by the author, the patient's outcome as follow: no choking, signs of aspiration pneumonia, weight loss and malnutrition with impaired swallowing, no muscle contracture and rigidity with impaired physical mobility, and no abnormal in neurological status or increased intracranial pressure with decreased intracranial adaptive capacity. This care experience can provide a reference for nurses to manage patients with post-traumatic hydrocephalus after intracranial hemorrhage to improve quality of nursing care.

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