「老有所依」一位老年病症候群之照護經驗

A Nursing Experience of Caring a Patient with Geriatric Syndrome

高齡化社會是現今不可逆的趨勢，高齡長者因老化衰退及多重慢性疾病複雜影響，面對疾病早期症狀無法及時明確判斷，產生老年病症候群（Geriatric syndrome），衍生多重共病問題，影響個人、家庭生活品質，造成社會醫療資源負擔。本個案為一位87歲長者，2年前因車禍導致創傷性腦出血，肌力退化後長期臥床，日常生活需仰賴配偶協助，面對個案衰弱照護問題及高齡案夫的照護疲憊，引發筆者探討動機，護理期間2019年1月8日至1月27日，筆者以Gordon十一項功能性健康評估工具進行整體性評估，針對急性混亂、衰弱長者症候群及照顧者角色緊張之健康問題，透過護理專業知識整合跨團隊資源，改善個案急性混亂問題，藉由復健提升自我照顧能力，引導個案及照顧者抒發長期照顧壓力，結合長照2.0擬定返家照護計畫。建議安排長者照護相關教育訓練，使醫護人員具備足夠專業知識與技能，利用老年周全性評估，提早篩檢衰弱因子，延緩老年病症候群產生。

With a growing elderly population, the trend of an aging society is irreversible. Geriatric syndrome, as a result of aging, declining function, and multiple chronic diseases, is difficult to be diagnosed by early symptoms. The multimorbidity of geriatric syndrome not only leads to a decline in individual and family life quality but also further increases the burden of healthcare resources. This article described the nursing experience of caring an 87-year-old elderly with traumatic intracranial hemorrhage, who relied on her senile husband heavily because of functional decline after a car accident 2 years ago. The nursing period was from January 8-27, 2019. Using Gordon eleven functional health patterns assessment, we identified three main health problems, including acute confusion, geriatric syndrome, and caregiver role strain. The author integrated resources from cross-functional teams with nursing expertise to improve her acute confusion condition, elevated her self-care ability through rehabilitation, encouraged the patient and caregivers to express long-term care pressure, and integrated resources from Long-term Care 2.0 to meet the patient’s home-care needs. We suggest that education courses about elderly care are necessary, so that medical staff have sufficient knowledge and skills to comprehensively screen for debilitating factors in advance and postpone the aging process.