運用跨團隊資源協助一位腦中風長者之居家護理經驗

A Home Care Experience of Using Interprofessional Collaborative Practice to Assist a Stroke Elderly

本文旨在描述運用跨團隊資源照護ㄧ位92歲罹患腦中風長者達身心調適之居家護理過程，筆者於2020年11月18日至2021年3月15日照護期間藉由多次居家訪視及持續電訪方式，運用周全性老人評估發現個案因二次中風後有吞嚥及身體活動功能障礙，轉介長照相關資源包括:語言治療、物理治療、職能治療、營養及心理治療的專業服務資源，協助個案及家屬共同參與復健計畫與活動，執行吞嚥訓練及復健計畫。除健康問題外，更因身體功能退化繼而出現無望感心理情緒問題，筆者鼓勵並接受個案正負向感受的表達，運用生命回顧引導重新檢(審)視自我生命價值，找出復能動機，讓個案改善吞嚥嗆咳狀況並成功移除鼻胃管後，能舒適安全的由口進食；同時也鼓勵個案走出戶外，以維持身體與社會功能的最佳狀況，提升個案與照顧者之生活品質，期望此護理經驗有助提升護理人員對腦中風居家長者復能之照護。

This article describes the home care process for a 92-year-old patient who suffered a stroke, focusing on improving both physical and mental conditions through interprofessional collaborative practice (IPCP). From November 18, 2020, to March 15, 2021, a comprehensive assessment was conducted through multiple home health visits and phone interviews. The assessment revealed that the patient experienced dysphagia and impaired body movement following a second stroke. To address these issues, the patient was referred to a range of professional resources including a speech therapist, physical therapist, occupational therapist, dietitian, and psychologist. These specialists, along with the patient’s family, implemented rehabilitation activities, swallowing training, and tailored rehabilitation plans. In addition to health problems, the patient faced emotional challenges, including feelings of hopelessness due to physical deterioration. The author encouraged the patient to express both positive and negative feelings and used life review methods to help the patient regain a sense of self-worth and motivation for rehabilitation. As a result of the interventions, the patient successfully overcame swallowing and coughing issues after the removal of the nasogastric tube, allowing for safe and comfortable eating. The author also encouraged outdoor activities to maintain physical and social functions, thereby enhancing the quality of life for both the patient and their caregiver. This nursing study demonstrates an effective approach to improving home care quality for stroke patients through collaborative, multidisciplinary efforts.