本篇報告為應用中西醫結合照護一位顱內出血於中醫門診就診之個案。護理期間於2011年4月29日至7月18日。運用中醫四診：望、聞、問、切及西醫身體評估進行完整性評估，發現個案長期受苦於身體活動功能障礙(氣虛血瘀脈絡痺阻)、便秘(氣血虛秘)及焦慮(氣滯血瘀)等問題。於護理過程中指導與示範由家屬協助個案中西醫飲食、運動及穴位按壓，改善個案因頭部創傷後肢體活動功能障礙，及緩解便秘症狀進而降低生理不適；給予持續性關懷、傾聽並鼓勵個案說出內心感受，提升個案及家屬對自我照顧的認知進而降低焦慮感。此個案之照護因限於門診看診時間匆促，致拉長健康問題解決的時間，建議於急性期即結合中西醫照護至後續門診之持續照護；期望分享此獨特性照護經驗供參考。

This report is an application of integration of Chinese and Western Medicine to care the sequels of a head injury patient in outpatient care. The care period was between April 29 and July 18, 2011. The nurse applied traditional Chinese medicine diagnostic methods: inspection, smell, questioning to do holistic assessment and identified three nursing problems: physical activity dysfunction and constipation, anxiety with lack of self care knowledge. Nursing care plan included guiding the family caregiver to deal with patient’s diet and exercise need, demonstrating the acupressure technique to resolve the activity dysfunction and constipation problem, and providing continuity humanistic care to enhance patient and family’s self care knowledge. This nursing care experience demonstrated that combination of Chinese with Western medicine may effectively improve patient’s physical, psychological and social problems due to head trauma.