一位初次缺血性腦中風患者之護理經驗

本文旨在探討一位84歲女性患者初次腦中風導致左側肢體偏癱之護理經驗。護理期間自2017年6月15日至7月17日，運用Gordon十一項健康功能型態為評估工具，藉由觀察、會談、身體評估及查閱病歷方式收集整體性健康問題，確立個案主要的護理問題為身體活動功能障礙、組織完整性受損及照顧者角色緊張。筆者於護理過程中把握腦中風復健的黃金時期，提供被動全關節運動及執行個別化的復健運動計畫，增強個案的肌肉力量及關節柔軟度，避免關節攣縮。協助案媳定時翻身並提供翻身擺位技巧及傷口護理，促進壓瘡傷口癒合及預防合併症的發生。運用主動關懷、傾聽、陪伴及同理心方式，鼓勵表達內心的感受，與案媳建立良好的護病關係，共同參與照護過程，透過回覆示教方式，增強案媳的照護技能，以及轉介出院準備服務，積極提供返家用物準備事宜，並協助輔具之申請，最後個案如期出院。電話追蹤得知返家後能適應新的生活並得到適切的後續照顧，得以減輕主要照顧者的壓力及焦慮，藉此護理經驗分享能提供護理人員日後照護此類病患之參考。

關鍵字

缺血性腦中風；身體活動功能障礙；組織完整性受損；照顧者角色緊張

並列摘要

This article aims to explore the nursing experience of an 84-year-old female patient with a first time ischemia stroke that causes hemiplegia on the left side of the limb. From June 15th to July 17th, 2017, Gordon's 11 functional health pattern assessment to collect and analyze the data of the client with the strategies of observation, interview, physical assessment, and medical records. The identified health problems included: impaired physical mobility, impaired tissue integrity, and caregiver role strain. In the process of nursing, the author grasps the golden period of the stroke rehabilitation, provides passive range of motion exercise and implements individualized rehabilitation program, enhances the muscle strength and joint softness of the client, avoids joint contracture; assisting the daughter-in-law to turn over the client regularly and provide turning-over skills and wound care to promote the healing of pressure sore wounds and prevent the occurrence of comorbidities; use active caring, listening, companionship and empathy to encourage expression of inner feelings and establish a good relationship with the daughter-in- law and participate in the nursing process. The daughter-in-law in the nursing process, enhance the nursing skills of the daughter-in-law through referral teaching methods, and refer to the discharge planning, actively provide preparations for returning home goods, and assist in applying for devices. The final client is discharged on time. By telephone track, the client could adapt a new life and receive appropriate follow-up care after returning home. Hence, the caregiver could alleviate the stress and anxiety. This nursing experience in this article could serve as a reference for caring stoke patients in the future.