一位初次腦中風病人轉銜長照復能之護理經驗

Nursing Experience in Bridging a First-Time Stroke Patient to Long-Term Care Rehabilitation

林君玲(Chun-Ling Lin)；徐琬茵(Wan-Yin Hsu)

初次腦中風 ； 居家復能 ； 居家訪視 ； first-time stroke ； home-based rehabilitation ； home visit

志為護理-慈濟護理雜誌

22卷6期（2023 / 12 / 01）

119 - 128

繁體中文;英文

本文探討初次腦中風男性，低收單親並照顧三名未成年子女重擔，透過會談感受個案情緒低落進而引發探討動機。護理期間2019年9月3日至9月10日，藉由照護、會談，運用Gordon十一項功能性健康型態進行評估，跨團隊合作照護模式及出院隔日至家中訪視，確立健康問題有：無效性健康維護能力、肢體活動障礙、焦慮。經由良好護病關係，提供照護指導，陪伴傾聽並協助改善焦慮，鼓勵復健，透過無縫接軌居家照顧及復能；藉由居家訪視發現居家環境髒亂，透過社區資源讓環境獲得改善及取得更多社會資源。建議醫院成立愛與關懷小組深耕社區，透過居家訪視提供協助，讓個案受到妥善居家照顧，避免再入院，提升居家照顧品質、降低醫療資源耗用。

This article explores a male first-time stroke patient who was a low-income single parent taking care of three minors. During interviews, the case's low moods were observed leading to motivation for further investigation. The nursing period was from September 3 to September 10, 2019. By providing care, conducting interviews, and using Gordon's 11 functional health patterns for assessment, a cross-disciplinary team collaborated on the care model and conducted a home visit on the day after discharge. Several health problems were confirmed: Ineffective health maintenance ability, physical activity impairment, and anxiety. Through a good nurse-patient relationship, care guidance was provided, and the patient was accompanied and listened to, which helped improve anxiety, encouraged rehabilitation, and achieved seamless home care and rehabilitation. During the home visit, the home environment was found to be dirty and disorganized. Through community resources, the environment was improved and more social resources were obtained. It is suggested that hospitals should establish care teams to deepen community involvement, provide assistance through home visits, ensure proper home care for the patient, reduce the chance of rehospitalization, enhance the quality of home care, and reduce the consumption of medical resources.

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