運用多重感覺刺激照護腦梗塞昏迷病患之護理經驗

Nursing Experience of a Comatose Patient with an Middle Cerebral Artery Infarction Using a Multi-sensory Stimulation Program

本文描述一位因大腦中動脈梗塞導致意識不清、身體活動功能障礙之病患護理經驗，筆者於93年2月25日至3月8日之照護期間，運用羅式適應模式評估病患有知覺感覺改變、身體活動功能障礙及皮膚完整性受損之主要護理問題，依病患相關生活習慣將多重感覺刺激計劃溶入護理活動中，視其進展提供不同重點的感覺刺激訓練，使病患昏迷指數由6分至出院時達11分，改善病患意識狀況及身體活動功能，減少長期臥床合併症之產生。建議護理人員除運用多重感覺刺激計畫於頭部外傷昏迷病患外，亦可應用於因腦中風昏迷之病患。

This article describes nursing experience of a comatose patient with a MCA infarction. The author assessed the patient's health condition guided by Roy's adaptation model from February 25th to March 8th 2004. The major nursing problems were perceptual alterations, impaired physical mobility and impaired skin integrity. Based on the social history of the client that separated vision, hearing, smell, touch and motor functions, a multi-sensory stimulation program was introduced into the patient's daily nursing care activities. The nursing intervention varied with the patient's response to the different aspects of the program. The client's conscious status increased from 6 on the Glascow Coma Scale to 11. The author suggests that the multi-sensory stimulation program does not only work well with head injury comatose patients but is also useful with cerebrovascular accident comatose patients.