照顧一位缺血性腦中風病人之護理經驗

本文描述一位第二次缺血性腦中風的個案，在發作後三小時內接受靜脈血栓溶解劑後入腦中風加護病房密切監測治療，於加護病房第五天生命徵象趨穩後，開始積極執行床邊物理復健治療的護理經驗。照護期間自2013年8月3日至8月12日，運用Gordon十一項健康功能型態為評估架構，藉由觀察、評估、會談及病程紀錄收集、分析資料，確立個案面臨的健康問題有：腦組織灌流失效、身體活動功能障礙及知識缺失。在護理過程中運用個別性護理措施，於急性期密切進行神經學評估、嚴密監測生命徵象、出血評估及心理支持，並把握腦中風後前六個月的黃金治療時間，鼓勵個案儘早執行床邊主動、被動全關節運動，在跨專業團隊協助與合作下，共同擬定復建計畫，幫助個案逐漸增進自我照顧能力，護理過程中持續給予個案情緒支持、給予正向鼓勵及病況相關資訊，加強個案對腦中風的認識，預防再次腦中風。2013年8月12日個案轉出至普通病房後，持續追蹤個案復健情形，並轉介出院準備服務小組，幫助個案及照顧者皆能獲得持續性照顧，使個案能維持最大肢體功能，提升其生活品質。期望藉此經驗分享，能提供護理人員對於腦中風病人之照護上的參考。

關鍵字

缺血性腦中風；護理

並列摘要

This report describes a nursing care experience of a patient diagnosed with recurrent ischemic stroke during his hospitalization in 2013. The patient received thrombolytic therapy within 3 hours of disease onset in the intensive care unit and began bedside rehabilitation in 5 days. Through observation, evaluation, interviewing, data collection and data analysis, the author used Gordon's 11-item Functional Health Patterns to assess major nursing problems. Problems included ineffective cerebral tissue perfusion, impaired physical mobility, and impaired cognition. Individual nursing care interventions in the acute phase included close monitoring of neurological status, vital signs, signs of bleeding, psychological support and early bedside active and passive range of motion exercise. The multi-disciplinary team developed coordinated rehabilitation plans that helped the patient to gradually regain self-care skills, to provide continuous emotional support, encouragement and education to prevent disease recurrence. After the 10-days ICU stay of the patient, the author continued to track the patient's progress at the medical unit regarding rehabilitation and referral to discharge planning team to ensure maximum outcome of physical functioning and quality of life. The author wishes to share this experience as a reference for future care of stroke patients.

並列關鍵字

ischemic stroke ； nursing

參考文獻

Jauch, E. C., Saver, J. L., Adams, H. P., Bruno, A., Connors, J. J., Demaerschalk, B. M., ... Yonas, H. (2013). Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 44, 870-947. doi:10.1161/STR.0b013e318284056a

Summers, D., Leonard, A., Wentworth, D., Saver, J. L., Simpson, J., Spilker, J. A., . . .& Mitchell, P. H. (2009). Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: A scientific statement from the American Heart Association. Stroke, 40(8), 2911-2944. doi:10.1161/STROKEAHA.109.192362

何怡慧、劉秀月、黃純德（2014）．復健期腦中風病患咀嚼吞嚥障礙盛行率及初步篩檢徵象之探討．護理雜誌，61（2），54-62。