英文摘要
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This report describes the post-surgery nursing care for a patient with traumatic brain injury. The author applied the Gordon Functional Health Pattern, which includes 11 categories, combined with observation, communication, and medical record review skills to assess the patient when taking care of the patient during December 19th to 30th, 2019. Three major nursing diagnoses were concluded: decreased intracranial adaptive capacity, impaired physical mobility, and anxiety. The author built trust with the patient, encouraged the patient to express feelings, translated and explained treatment process with the assistance of the patient's friend, provided individual care, and assessed vital signs and neurological reactions closely to prevent secondary traumatic brain injury. The author also cooperated with the medical team to build a rehabilitation plan for the patient, assisted the patient to carry out the plan, and encouraged and supported positively the patient to increase the patient's self-care ability and willingness to exercise actively to return to usual life as early as possible. Since the patient had communication and financial difficulties, the author used graph cards and translation apps and cooperated with social workers to solve the problems. The patient's level of anxiety decreased after connecting with the patient's family in Indonesia and receiving family supports using videoconferencing apps. The author's nursing experience can be used as a reference for healthcare professionals when taking care of migrating patients.
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