「急」刻救援──急性腦中風病人面臨施打rt-PA的急診護理經驗

Emergency Nursing Experience of A Patient Receiving Intravenous rt-PA for Acute Stroke

本文旨在闡述一位急性缺血性腦中風病人，面臨需立即決策施打血栓溶解劑（rt-PA）與否之急診護理經驗。護理期間為2013年09月25日21：08至2013年09月25日22：58，筆者以Gordon十一項健康功能型態作為評估架構，運用身體評估、觀察、會談、病歷查閱等方式收集資料，確立個案主要健康問題為抉擇衝突、身體活動功能障礙、潛在危險性損傷－－出血。照護期間藉由主動關懷、示範教學方式協助個案解決肢體乏力導致的生理需求與不適，避免中風可能導致的續發性傷害，並以有效溝通、諮商原則協助個案釐清對rt-PA的迷思、克服抉擇困難，幫助在時效內做出決定。急性缺血性腦中風發作三小時內／到院60分鐘內施打rt-PA為黃金搶救時間，抉擇衝突恐延誤施打契機、影響預後，此外對突發性身體功能喪失、預防rt-PA施打後的出血高風險照護，急診首當要責，故成為選案分享之理由。基於本照護經驗，建議急診護理人員面對抉擇衝突的病人，需主動關懷、運用開放性溝通、探索病人困難決策的主因、耐心提供諮詢及傳遞利弊訊息，幫助病人剖析自身需求，在時效內做出對自己最有利的決策，以落實「以病人為中心」的護理。

This paper describes an emergency nursing experience when assisting a patient with acute ischemic stroke and the rapid decision-making required regarding the use of a thrombolytic drug, rt-PA. The nursing period was from 21:08 to 22:58 on September 25, 2013. We used Gordon's 11 functional health patterns as the assessment framework and collected data through physical assessment, observations, conversations, and a chart review. The health problems included decisional conflict, impaired physical mobility, and risk of injury (bleeding). During the nursing process, we conducted several strategies, such as active attention and demonstration teaching in order to help meet the patient’s physiological needs and alleviate their discomfort resulting from limb weakness, thereby preventing secondary injury after a stroke. We also applied effective communication skills and counseling principles to help clarify the patient’s misconceptions about rt-PA and overcome decision-making barriers so as to make a decision within the limited time constraints. Patients with acute ischemic stroke should be given intravenous rt-PA within the golden hours (within three hours after onset/ 60 minutes after hospital arrival). However, decisional conflict can lead to decisional delay and adversely affect prognosis. In addition, the primary responsibilities of the emergency department are to provide care for patients with a sudden loss of mobility and to prevent the risk of bleeding after rt-PA administration. Therefore, we would like to share this nursing experience and suggest that emergency nurses should provide active attention, use open communication, explore decision-making barriers, and patiently provide consultation. Throughout, they should always explain the pros and cons to help patients who experience decisional conflict to better understand their own needs and thus make best interest decisions within the limited time constraints, thereby leading to more patient-centered care.