一位中風病人中期照護之出院準備服務經驗

A Discharge Planning to Transit a Stroke Patient to an Intermediate Care Facility

本篇個案報告是描述一位56歲男性，因中風導致肢體活動障礙衍生之後續照顧問題。個案於2011年12月17日經加護病房護理師轉介出院準備服務，筆者提供照護個案至2012年3月5日，期間進行5次訪視，5次電訪，藉由與個案及家屬互動、觀察、會談及需求評估等方式收集資料，依照個案需求提供適切的出院準備服務，在取得個案及家屬同意下，安排個案至中期照顧機構接受積極的復健治療，在個案恢復部分日常生活自理能力後，銜接社區照顧資源，協助個案回歸社區。本文作者希望藉由此個案的出院準備服務經驗，建構腦中風個案降低失能程度的照護模式-把握復健黃金時期，並利用中期照護資源銜接急性與長期照護，使個案可得到完整且持續性的照護。

This report describes a discharge planning to transit a 56 years old stroke patient from acute hospital to an intermediate care facility. The physically disable caused by acute stroke induces aftercare problem. The patient was referred to discharge planning service from intensive care unit on December 17, 2011. To March 5, 2012, the discharge planner provided 5 ward visits and 5 telephone contacts to identify patient’s continuity care needs. With the agreement of patient and his family, the discharge planner referred the patient to an intermediate care facility to receive active rehab training. When patient’s self care ability had increased, and community long term care resource was activated, the patient was successfully returned to home. The service of intermediate care to reduce the degree of disability need to be structured to fulfill the continuity care needs of stoke patients.