一位腦中風失能病患出院準備服務之護理經驗

本篇個案報告在於分享一位因腦中風引起重度失能之26歲年輕女病患，於急性醫療後，筆者運用完整的出院準備服務概念架構，協助個案順利返家及整個家庭充分運用資源並重新適應生活的照護經驗。出院準備服務介入過程自2005年3月18日至同年5月12日，此過程藉由觀察、會談、身體評估、家庭評估、加上出院後的電訪追蹤進行資料收集，並確立其主要護理問題包括：照顧者角色緊張、家庭運作過程改變、社會資源運用相關知識缺乏等。在照護期間筆者扮演聯絡者、諮詢者、指導者與傾聽者的角色，協助家屬面對個案失能的衝擊及家庭的重建，使個案得以獲得適切的後續照護，更突顯個案管理師於出院準備服務的重要角色與功能。

關鍵字

腦中風；失能病患；出院準備服務

並列摘要

This case study aims to share the writer's nursing experience in which the sound framework of discharge planning was applied to a twenty-six year old female patient, suffering from profound disability caused by cerebrovascular accident, after medical treatment and thus the client could go back to home and adapt herself to the new life with the resources of the whole family being fully used. The nursing care was delivered from 18 March 2005 to 12 May 2005 by means of observations, interviews, physical evaluations, family evaluations, and follow-up investigations by phone calling after the client’s discharge from the hospital .The relevant data were collected and the following nursing issues were worked out including caregiver role strain, change of the family processes, and knowledge deficient about sociala. During the nursing care period, the writer played the roles of a contact person, a consultant, a counselor, and a listener so as to help the family cope with the impact caused by the client’s disability as well as the issue of rebuilding of the family and, therefore the client could get proper aftercare. Moreover, the importance and the function of the case study researcher in the discharge planning are also highlighted.