運用行為治療於思覺失調症老年期病人之護理經驗

The Application of Behavioral Therapy in Nursing Care for Elderly Patients with Schizophrenia

本文描述運用行為治療方式改善一位因負性症狀影響，已20多年未曾沐浴之71歲思覺失調症個案的護理經驗。護理期間為2023年9月14日至11月13日，筆者藉由會談、觀察等技巧蒐集資料，並使用生理、情緒、智能、社會及靈性五大層面進行護理評估，確立個案有不遵從／與疾病認知不足有關、自我照顧能力缺失－－沐浴、修飾／與精神症狀干擾有關等護理問題。筆者藉由主動關懷與個案建立良好護病關係，掌握個案獨有服藥模式，並透過漸進式引導方式改善個案的清潔認知，激勵個案產生改善意願。與個案及醫療團隊共同制定個別化行為契約目標及內容，採用代幣制度，藉由正向增強物，讓個案學習並維持所被期待的行為模式。另鼓勵個案參加支持團體，增加社交互動，建立疾病共同性。形成正確的疾病認知，並肯定個案的正向變化，維持良好的醫療遵從性。此次透過行為治療有效改善個案的不遵從服藥及自我照顧能力，進而增進其生活品質。建議未來強化跨專業資源整合，結合社工或社區關懷訪視員延伸出院後照護，穩定生活技能與支持系統。期待透過分享此經驗，提供相關精神照護人員參考。

This article describes the nursing experience of applying behavioral therapy to improve the self-care ability of a 71-year-old patient with schizophrenia who, driven by the negative symptoms of the illness, had not bathed for over 20 years. During the nursing care period from September 14 to November 13, 2023, data were gathered through interviews and direct observations using a holistic five-dimensional assessment—encompassing physical, emotional, cognitive, social, and spiritual domains—which identified primary nursing problems of treatment nonadherence due to poor insight and a severe self-care deficit in bathing and grooming. To address these challenges, the nurse established a trusting therapeutic relationship through proactive care, decoded the patient’s unique medication-taking patterns, and worked collaboratively with the healthcare team and the patient to establish individualized behavioral contracts. By incorporating a token economy with positive reinforcement, the patient was systematically motivated to rebuild hygiene habits and maintain desired self-care behaviors, while participation in support groups further enhanced his social interaction and reinforced illness awareness. Ultimately, these targeted interventions led to correct illness perceptions, sustained medication compliance, and a drastically improved quality of life, demonstrating that behavioral therapy can effectively restore basic self-care in geriatric psychiatric patients and suggesting that future clinical practice should integrate validated, reliable assessment scales alongside routine behavioral observations.