照顧一位接受血栓溶解劑治療的急性缺血性腦中風病人之護理經驗

本文探討一位因急性缺血性腦中風病人接受血栓溶解劑治療的護理經驗。護理期間以Gordon十一項功能性健康模式為護理評估架構，以訪談、觀察及傾聽等方式，發現其主要有潛在危險性損傷、身體活動功能障礙、穿著與進食自我照顧能力缺失、身體心像紊亂等健康問題。針對其健康問題，首重於預防使用抗凝血劑後出血情形，再藉由主動關懷及適時給予衛教，針對病人自我照顧與偏癱肢體訓練，擬定復建計畫，增加自我照護能力，協助其發揮最大的身體可用功能，增加復健活動的參與度及信心，讓病人瞭解並接受其身體外觀及功能的改變使其增加信心，進而改善身體心像紊亂。期望藉由此護理經驗分享，能做為其他護理同仁照護之參考。

關鍵字

缺血性腦中風；血栓溶解劑；身體活動功能；身體心像

並列摘要

This article describes the nursing experience of caring for an acute ischemic stroke patient who suffered thrombolytic therapy. Patient's condition was assessed based on Gordon 11-item Healthy Assessment by providing direct clinical nursing care, observations, and interviews. The major nursing problems of the patient, including impaired physical mobility, risk for injure, self-care deficit, and body image disturbance. Prevent bleeding after thrombolytic therapy is most important nursing. Then through building up and treating social relationships among the patient, providing nursing intervention according these nursing problems. Helping him draft plans about rehabilitation and complete self care. Make patient understand and accept the changes in his physical appearance and function to make it more confidence, then improving body image disturbance. The author hopes that this article can serve as a clinical care reference for other nurses taking care of similar cases in the future.

並列關鍵字

ischemic stroke ； thrombolytic agents ； physical mobility ； body image

參考文獻

Bernhardt J, Churilov L, Ellery F, Collier J, Chamberlain J, Langhorne P, Lindley RI, Moodie M, Dewey H, Thrift AG, Donnan G; AVERT Collaboration Group.( 2016). Prespecified dose-response analysis for A Very Early Rehabilitation Trial(AVERT).Neurology,86(23),2138-45. doi:10.1212/wnl.0000000000002459

李雅雯、陳君山、黃鳳珍(2011) ‧一位年輕中風病患之護理經驗‧嘉基護理，11(1)，24-33。