運用多重感覺刺激照護一位糖尿病併發敗血症昏迷患者之護理經驗

Application of Multi-sensory Stimulation for a Coma Patient with Diabetes and Sepsis

本篇報告是運用多重感覺刺激照護一位糖尿病老婦女因尿路感染引發敗血症、急性呼吸與腎衰竭而昏迷個案之經驗。護理期間為98年12月1日至12月8日。照護期間以觀察、身體檢查和家屬討論的方式來收集資料，並運用羅氏適應模式評估為評估工具，確認個案三個主要的護理問題為：知覺感覺改變、身體活動功能障礙及皮膚完整性受損。筆者依個案相關生活習慣將多重感覺刺激計劃融入護理活動中，使個案昏迷指數由ElVtM3分改善至轉出加護病房時達E4VtM5分。另外，於護理期間妥善照護個案紅臀傷口，使多處破皮傷口癒合。建議護理人員能將多重感覺刺激計畫運用於常規護理，以促進昏迷患者恢復。

This report describes the nursing experience of an elderly female coma patient with sepsis, acute respiratory failure and renal failure resulting from uterine tract infection. The care period was from December 1 to December 8, 2009. The author collected information through observation and physical examination of the patient, in addition to interviews with members of the patient's family. Based on Roy's adaptation model, the author identified three major health problems, including perceived sensory changes, physical activity dysfunction and impaired skin integrity. The author incorporated the multi-sensory stimulation program into nursing activities based on the patient's living habits. The results showed that the patient's rating on the Glasgow coma scale improved from E1VtM3 to E4VtM5 by the time she was transferred out of the intensive care unit. The multiple wounds on the patient's buttocks were also healed during this period of nursing care. The author concludes that nurses can use the multi-sensory stimulation program during regular nursing activities to improve recovery in comatose patients.