一位缺血性腦中風患者接受血栓溶解劑治療的急診照護經驗

本文敘述一位初次罹患缺血性腦中風患者，面臨突來的疾病，需在有限的時間內決定是否施打血栓溶解劑的急診護理經驗。照護期間於2019年11月20日08：30到12：30，運用Gordon十一項功能性健康型態評估，經由觀察、會談、傾聽、關懷、身體評估及直接護理等方式收集資料，確認個案有：「焦慮／與急性腦中風注射血栓溶解劑的成效及預後有關」、「身體活動功能障礙／與腦中風導致左側肢體乏力，無法自行完成床上（翻身、坐起及使用尿壺）有關」、「照顧者角色緊張／與照顧經驗不足及病人病情預後無法預期有關」。照護期間運用主動關懷、非語言肢體接觸、耐心傾聽和陪伴，與個案及家屬建立良好護病關係；當面對突發的腦中風導致身體活動功能受限及是否立即接受血栓溶解治療的抉擇，引發病人及家屬極大心理壓力及焦慮，利用靈敏的觀察力發現其需求，鼓勵個案及家屬說出心裡擔憂，運用醫療團隊合作及相關疾病的衛教資料，讓病人及家屬獲得相關知識及協助，並於關鍵治療時間內接受血栓溶解劑治療，進而緩解疾病帶來之衝擊；照顧病人部分，提供中風照護相關知識及護理技巧，以提升個案生活品質。期許透過此次的照護經驗分享，供日後照護類似個案參考，讓護理獨立功能角色得以展現。

關鍵字

缺血性腦中風；血栓溶解劑；焦慮

並列摘要

This article describes the emergency care experience of a patient suffering from ischemic stroke for the first time, facing a sudden illness, and having only a limited time to decide whether to administer a thrombolytic agent or not. During the care period from 08:30 to 12:30 on November 20, 2019, Gordon's eleven functional health assessments were used to collect data through observation, interviews, listening, psychological support, physical assessment and direct care. We confirmed that the case had, the following problems: first, anxiety, which related to the effectiveness and prognosis of thrombolytic injection for acute stroke, second, physical dysfunction, which related to stroke-induced weakness of the left limb and inability to complete the bed (turning over, sitting up, and using urinal),third, The role of caregiver is tight, which related to insufficient care experience and unpredictable prognosis of the patient condition. By using active care, nonverbal physical contact, patient listening and companionship during the nursing period we established a good nursing relationship with the case and family members. A great psychological stress and anxiety will be aroused as the patient's and their families faced with a Sudden stroke that leads to limited physical activity and have to decide whether or not to receive the thrombolytic therapy immediately. We can use sensitive observation to discover their needs, encourage the case and family members to express their worries, use medical team cooperation and health education information about related diseases, so that patients and family members can obtain relevant knowledge and assistance. The patients could receive thrombolytic treatment within the critical treatment time to alleviate the impact of the disease. For the part of patient care ,we can provide stroke care-related knowledge and nursing skills to improve the quality of life of the case. It is hoped that through this sharing of nursing experience, it can be used as a reference for similar cases in the future, so that the independent role of nursing can be demonstrated.