一位腦中風個案之『出院準備服務』之經驗

A Nursing Experience of Discharge Planning Service for a Patient With Cerebrovascular Accident (CVA) Patient

行政院衛生署96年國人十大死因統計，腦血管疾病高居死亡原因第三位，部分個案罹病後常併發不等程度之功能受損，藉由完善「出院準備服務」計劃之擬定與執行，能有效提高主要照顧者準備度及照顧技能，減少個案後續合併症產生；本文為探討一位腦中風個案因主要照顧者照顧經驗及壓力因應能力不足，引發個案健康照護相關問題導致重複入院多次，經身體、情緒、智能、社會、靈性五大層面整體性護理評估發現個案有：「皮膚完整性受損」、「呼吸道清除功能失效」、「身體活動功能障礙」、「照顧者角色緊張」等健康問題，護理過程中筆者運用出院準備服務概念，針對個案健康問題擬訂相關護理措施，並教導主要照顧者學習照護技巧，期間主要照顧者除熟練各項照護技巧及相關護理措施外，更能適時處理個案健康問題，有效促進個案壓瘡傷口癒合、避免肢體攣縮惡化及預防疾病合併症的發生；結合出院準備服務團隊的運作，依案家的照護需求，積極提供社會福利資源與出院用物準備事宜，除了協助個案得到適切的後續照顧，亦能維持家庭功能正常運作，藉此照護經驗與出院準備服務人員分享。

Cerebrovascular accident (CVA) is the third leading cause of death of 2007 in Taiwan. Following CVA, many patients suffer different levels of disability. However, the evidence reveals that a well-prepared discharge planning service improves caregiver skills and patient care and, furthermore, reduces the occurrence of complication. In this article we present the case of a patient with CVA who was repeatedly admitted to our hospital because of home care knowledge and skills deficiency and lack of communication and support among family members.The main caregivers experienced psychophysical fatigue and fear, which diminished family coping ability. We applied comprehensive nursing assessment to evaluate the physiology, mental acuity, social nature and spirituality of the patient. We confirmed that the main nursing issues for this patient were impaired body and skin integrity, ineffective airway clearance, impaired mobility and caregiver role stain. We utilized concepts of discharge planning and emphasised management and preparation for care after discharge. The nursing plans focused on the training skills of the caregiver regarding pressure sore care, limb stricture prevention and psychological support for the family. After discharge, we continuously provided a discharge plan together with social welfare services according to the needs of the patient and the family. The plan successfully enhanced the caregiver’s care ability and maintained family functions.