運用復能照顧計畫於一位失能合併壓傷個案之居家照護經驗

本文運用復能照顧計畫於一位失能合併壓傷個案之居家照護經驗。個案中風後無法獨自移位，長期坐臥致身上多處壓傷，其照顧者亦高齡者，老老照顧是現今社會問題，個案及照顧者缺乏正確傷口照護知識，傷口不易癒合、沐浴清潔困難、心理焦慮。筆者於2022年1月11日至2022年6月5日，藉由電訪、家訪及直接照護蒐集資料，運用Gordon十一項功能性健康型態評估，確立個案健康問題有：一、皮膚完整性受損；二、自我照顧能力缺失；三、焦慮三項問題。照護過程，筆者發揮居家復能護理師角色，教導正確無菌換藥流程，協助個案提升自我照顧能力、透過放鬆技巧及轉移注意力，使壓傷傷口癒合與降低焦慮，克服疾病帶來衝擊。建議未來居家護理師可連結國家衛生政策及非正式資源為個案提供復能到宅照護，使個案獲得持續性且多元個別照護。

關鍵字

壓傷；復能照護計畫；失能

並列摘要

This article shares the home-care experience of using the Rehabilitation Care Plan to assist a case of diabetes and stroke with pressure injury. The patient was unable to move independently after stroke and suffered multiple pressure injury because of long-term sitting and lying. The elderly caring for another elderly person is a contemporary issue, as both case and caregivers lack proper wound care knowledge as wounds are not easy to heal, bathing and cleaning were difficult, so both the patient and caregiver suffer from psychological anxiety. From January 10 to June 5, 2022, Gordon's 11 Functional Health Assessment were employed as the assessment framework. Data was collected through telephone interviews, home visits and integrated direct care services. The author established three issues regarding patient’s main health conditions, including impaired skin integrity, poor self-care, self-perception and conceptual patterns. During the nursing process, the author plays the guiding role by teaching the correct procedure of changing sterile, assisting the case to improve self-care ability, and through relaxation techniques and diverting attention to overcome the problems, hence reduce anxiety to overcome the impact of the disease. It is recommended that home-care nurses can link national health policies and informal resources to provide rehabilitation home care for patients in the future, so the patients can receive continuous and diversified individual care.