一位反覆住院之雙相情緒障礙症患者及其家屬之跨團隊合作照護經驗

Nurses’Role in Resolving Health Problems of Repeatedly Hospitalized Patients with Bipolar Disorder and their Families through Implementation of an Inter-Professional Collaborative Practice

雙相情緒障礙症多影響心情、家庭及工作表現，倘若在疾病進展過程中缺乏足夠之社會支持及完善出院服務，易提高反覆住院機率，進而增加醫療成本支出。本文描述一位年輕且反覆住院之雙相情緒障礙症病人，並以家庭護理為本文重點。精神衛生護理師藉護理角色引領各專科啟動跨領域團隊合作照護，從2017年08月04日至11月08日，以觀察、心理會談及整體性護理評估工具收集資料，歸納護理問題為：因應能力失常、健康管理失常及危及家庭因應能力等，依需求予個別化照護措施。以傾聽、同理與引導病人和家屬陳述情緒感受，建構互動式治療性人際關係，藉跨領域團隊合作角度啟動個案討論會議以及整合病人醫療照護計畫，最終強化出院後醫療網絡與社會支持系統，使健康問題逐步改善，邁向穩健復元之路。

Bipolar disorder affects mood, family, relationships, and work performance. Further, as the illness progresses, all activities of daily living are impacted, particularly if patients lack a social system or have a discharge plan that exacerbates the risk of re-admission and related costs. This study describes nurses’ role in the recovery of repeatedly hospitalized patients with bipolar disorder through implementation of an inter-professional collaborative practice. Participants were psychiatric mental health nurses. Using a comprehensive assessment approach encompassing five major aspects, data were collected through observation and interviews from August 4 to November 8, 2017. The major patient problems identified by nurses included ineffective coping, ineffective health management, compromised family coping, etc. An individualized nursing plan was developed and included therapeutic listening, guiding patients and their families to express their minds, addressing any constricting interactive therapeutic interpersonal relationships, and integrating advanced care planning, medical network systems, and social support. The nursing process succeeded in resolving patients’ health problems and assisting patients to build a recovery lifestyle.