一位蜘蛛膜下腔出血青少年及其主要照顧者之成功護理經驗

Successful Nursing Experience of an SAH of Teenager and Her Primary Caregiver

10.6692/KJN-2017-34-2-10

李姿萱(Li-Zih Syuan)；蘇佩真(Pei-Chen Su)

蜘蛛膜下腔出血 ； 主要照顧者 ； subarachnoid hemorrhage ； primary caregiver

高雄護理雜誌

34卷2期（2017 / 08 / 01）

108 - 120

繁體中文

本文描述一位19 歲女性因腦動靜脈血管畸型(AVM)導致蜘蛛膜下腔出血(SAH)，影響個案肢體活動及自我照顧能力，腸道之消化吸收、排泄及家屬之角色適應等。筆者自2012 年10月25 日至2012 年11 月16 日藉由觀察、會談、溝通、傾聽、直接護理等方法收集資料，進行生理、心理、社會及靈性四層面的護理評估，發現健康問題為腦組織灌流改變、呼吸道清除功能失效、排便型態改變/便秘、照顧者角色緊張等。與家屬共同討論並擬訂個別的護理措施，護理人員扮演支持、教導與諮詢的角色，給予穩定腦組織灌流措施及解決便秘的問題，經由背部扣擊、定時翻身、增加活動量及增加水分攝取，主動關懷主要照顧者及回覆示教照顧技能等，結果使個案呼吸道通暢、腸胃道通暢，提供照顧者社會資源和熟悉照顧技能，進而維持個案良好的照護品質。

This article describes a 19-year-old woman suffering from cerebral arteriovenous malformation combined with subarachnoid hemorrhage. This affected patient mobility and self-care ability、intestinal digestion, absorption and excretion, and family roles of adjustment. From October 25 to November 16 in 2012, data were collected by the author from observations, communication, listening, and direct attendance. By the above approaches, the nursing problems were determined as: ineffective tissue perforation/cerebral, ineffective airway clearance, change of bowel habits/constipation, and caregiver role strain. Discussions with the family developed individual nursing intervention. The nurse played the role of support, teaching and consulting, by adopting relevant nursing interventions and nursing care, including: giving stabilization of brain tissue perfusion, and solving the problem of constipation through back percussion, regular repositioning, increased physical activity, and adequate hydration. Active participation and care training of the caregiver was applied. The results make a case to maintain the airway and gastrointestinal tract to maintain patency, while providing primary caregivers with use of social resources and familiarity with relevant skills, thus maintaining excellent care quality of patients.