協助一位腦中風病患及主要照顧者出院準備服務之經驗

A Nursing Experience of Discharge Planning for a Stroke Patient and Primary Caregiver

本文敘述一位70歲男性，罹患腦梗塞後造成身體功能障礙且日常生活需依賴他人，病況穩定後，除持續性復健治療外，還提供出院準備服務相關資源，協助個案順利出院之照護經驗。照護期間自2014年03月04日至2014年03月31日，藉由觀察、身體評估、會談等方式，以Gordon十一項健康功能形態評估照護問題，確立主要護理問題有：1)身體活動功能障礙，2)無力感，3)照顧者角色緊張，4)知識不足／社會資源不了解。護理過程著重於協助個案肢體功能障礙及心理層面之問題，藉由出院準備服務的介入，提供出院準備事宜及協助社會福利資源申請，減少個案家屬的無力感，讓個案能順利出院返家並重新適應新的生活照護模式。藉此經驗，期望能供日後護理人員照顧類似病患出院準備之參考。

This article described the nursing experience of a 70-year-old male patient who, after suffering from physical mobility impairment of cerebral infarction, became dependent in daily living. When the patient's condition stabilized, the author provided hospital discharge planning and available social resources, and the patient was then successfully discharged. The nursing period lasted from March 4 to March 31, 2014. The author collected data from observation, physical assessment, and interviews according to Gordon's 11 functional health patterns, and after evaluation, identified the following nursing issues: 1) physical mobility impairment, 2) helplessness, 3) caregiver role strain, and 4) deficient knowledge in social resources. The emphasis of the nursing process was placed on the rehabilitation of the patient's motor function impairment and psychological issues. Through the intervention of hospital discharge planning service, the author offered discharge planning and applied for social welfare to reduce the caregiver's helplessness, and the patient was successfully discharged and adapted to the new home care model. We hope this nursing experience could serve as a reference in the preparation and planning of discharging future stroke patients.