照護一位創傷性腦損傷術後青少女之加護經驗

An Intensive Nursing Experience of Caring for a Young Girl after Surgery for Traumatic Brain Injury

洪瑀婕(Yu-Chieh Hung)；鄭淑華(Shu-Hua Cheng)

創傷性腦損傷 ； 身體心像紊亂 ； 過渡理論 ； traumatic brain injury ； disturbed body image ； transition theory

若瑟醫護雜誌

18卷1期（2024 / 06 / 01）

115 - 128

繁體中文;英文

本篇描述一位20歲青少女因車禍導致創傷性顱內出血，緊急入開刀房進行減壓顱骨切除術，術後入住神經外科加護病房照護。評估發現個案除身體上的傷害不適外，無預期的身體外觀改變也讓年僅20歲的個案產生不安、焦慮等負向情緒，故引發筆者深入探討之動機。照護期間為2021年10月1日至10月9日，運用羅氏適應模式進行整體性評估，確立個案有呼吸道清除功能失效、顱內調適能力降低、身體心像紊亂、急性疼痛等健康問題。照護過程，偕同團隊教導個案執行心肺復健，增進呼吸肌力量，介入高頻胸壁震盪治療，並運用有效咳嗽技巧清除痰液，繼而順利移除氣管內管；介入降低顱內壓照護措施，評估疼痛指數後給予疼痛管理，同時穩定生命徵象以維持足夠顱內灌流，避免神經學惡化；運用過渡理論提供照護措施，主動予個案關懷及傾聽，偕同親友給予心理支持，提供傷口照護及頭髮生長週期等資訊，使個案正視並接受外觀改變之事實，並引導用正向態度去面對未來的人生。期望藉此護理經驗分享，提供臨床護理人員日後照護此類個案之實務參考。

This article describes the nursing experience for a 20-year-old female, who suffering from intracranial hemorrhage cause by traffic accident, admitted to the intensive care unit after undergoing emergency craniectomy surgery. After surgery, faced by the unexpected changes in physical appearance and physical discomfort that led the patient to a huge physical and mental impact. These are the reasons for selecting this case. The author applied observation and interview to collect data and assess the patient by means of using Roy adaptation model during the nursing period from October 1-9, 2021. It was confirmed that the patient had health problems such as ineffective airway clearance, decreased intracranial adaptive capacity, disturbed body image, and acute pain. Teaching patient to strengthening respiratory muscle and using effective coughing skills to weaning the respirator successfully. Performing appropriate nursing interventions to maintain adequate cerebral perfusion, keep vital signs stable and pain management to avoid neurological deterioration. Apply transition theory to listening and empathy to encourage individuals, and provide psychological support with family and friends to face up changes in appearance, teaching wound care and providing hair growth cycle information to help individuals to accept the impact of physical changes. It is hoped that the sharing of nursing experience will serve as a reference for taking care of such cases in the future, so that the role function of the nursing can be volatile.