一位創傷性胸主動脈損傷併急性腦中風病人之護理經驗

Nursing Experience of a Patient with Traumatic Aortic Injury Combined Acute Stroke

10.29494/LN.202009_21(3).0004

盧思羽(Szu-Yu Lu)；林秀惠(Shiu-Hui Lin)；林淑秋(Shu-Chiu Lin)；林玉菜(Yu-Tsai Lin)

創傷性主動脈損傷 ； 腦中風 ； 創傷症候群 ； traumatic aortic injury ； stroke ； traumatic syndrome

領導護理

21卷3期（2020 / 09 / 01）

36 - 49

繁體中文

本文係敘述照顧一位青少年因創傷性胸主動脈損傷術後併發急性腦中風的患者在復健期之護理經驗。護理期間自2016年07月23日至2016年08月18日，筆者以會談、傾聽、身體評估、觀察方式收集資料，經由歐倫（Orem）護理理論之評估，確立個案有吞嚥障礙、自我照顧能力缺失（進食、穿衣、如廁、沐浴）、創傷後症候群等問題。筆者運用歐倫理論之完全代償、部分代償及支持教育護理系統等概念提供個案適切之護理評估與護理過程，運用跨團隊合作共同擬訂復健計畫，提供個別性照護計畫，鼓勵參加急性後期照護計畫（post-acute care, PAC），激發個案對復健、預後之動機與增強信心。此外協同社會工作人員，提供案父社會支持系統，以減輕家庭經濟負荷。國內罕見類似個案照護經驗，筆者希望藉由此篇個案報告提出分享，期盼能對青少年發生重大創傷導致身心靈變化，提供適切照護措施，並給予護理同仁照護相關個案之參考。

This article describes about the nursing experience of caring for a teenager with acute cerebral stroke after Traumatic Aortic Injury. During the nursing period from July 23 to August 18, 2016, the author collected data through interviews, listening, physical examination and observation. Through the evaluation of Orem's nursing theory, we established the patient had suffered from dysphagia, self-caring deficit (eating, dressing, toileting, bathing) post traumatic syndrome and so on. The author applies the concepts of complete compensation, partial compensation, and support for the education and nursing system of Orem's nursing theory to provide appropriate nursing evaluation and nursing processes for this individual case and uses cross-team cooperation to jointly develop rehabilitation plans, provide individual care plans, and encourage participation in the late acute stage Post-Acute Care plan (PAC). Furthermore, it motivates the patient to rehabilitation, provided a better prognosis and enhanced the confidence of regaining heath. In addition, we contacted social worker to provide the social support system to the patient's father to reduce the financial burden on the family. This type of case is rare in our nation, the author was hoping that by sharing this case report, it will provide an appropriate caring reference for other nursing staff when dealing with teenagers, especially those who experienced severe trauma and lead to physical and psychological damage.

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