本文主要協助一位35歲正值青壯年期之男性，因右側枕骨顱內小腦出血，行血塊清除手術之全期護理經驗。護理期間自2015年1月16日至2月6日，筆者與個案及家屬建立良好護病關係外，並藉由會談、身體評估、觀察與查閱病歷方式收集資料，且依手術前、中、後期進行整體性的護理評估，歸納出主要健康問題有：焦慮/與即將面臨手術、手術過程不瞭解及未知的結果有關；潛在危險性損傷/與術中姿勢擺放不當造成神經肌肉血管及皮膚完整性受損有關；腦組織灌流改變/與顱內出血及顱內壓可能上升有關；身體活動功能障礙/與神經肌肉受損有關。筆者針對個案的問題擬訂護理計劃，提供個別性的措施紓解其術前之焦慮情緒，術中隨時注意擺位所成壓迫損傷的發生，以協助個案安全渡過手術期，術後注意顱內壓情形並使其順利進入復建期，適時的教導復健運動，並促進患者日後自我照顧的能力重回到社會。期望藉此護理經驗之分享，以提供日後照護此類個案之參考。 This case report depicted a 35year-old man who underwent clot removal surgery due to intracranial cerebral hemorrhage in right occipital. The patient was taken care of from January 16 to February 6, 2015. In addition to developing a good patient-nurse relationship with the patient and his family members, the author also used interviews, physical assessment, and observation and review on medical records to collect data. In addition, the author performed holistic nursing assessment before, during, and after the operation, and summarized the main health problems: anxiety, potentially dangerous damage, change in brain tissue perfusion, motor function impairment. The author developed a nursing plan for the health problems encountered by the patient, took individualized measures to relieve his preoperative anxiety, and paid attention to the occurrence of compression injury caused by posture at any time to help the patient go through the operative period safely. After the surgery, the author paid attention to intracranial pressure to enable the patient to successfully enter the rehabilitation stage, instructed him in rehabilitation exercise, and improved his future self-care ability to return to the society. It is hoped that the sharing of this nursing experience can be provided as reference for future care of similar cases.
