照顧一位缺血性腦中風病人之護理經驗

A Nursing Experience for a Patient With Ischemic Stroke

10.6530/YYN/2017.4.4

蔡雅婷(Ya-Ting Tsai)；張瓈方(Li-Fang Chang)；尹玓(Ti Yin)

缺血性腦中風 ； 護理 ； ischemic stroke ； nursing

源遠護理

11卷3期（2017 / 11 / 01）

65 - 73

繁體中文

本文描述一位第二次缺血性腦中風的個案，在發作後三小時內接受靜脈血栓溶解劑後入腦中風加護病房密切監測治療，於加護病房第五天生命徵象趨穩後，開始積極執行床邊物理復健治療的護理經驗。照護期間自2013年8月3日至8月12日，運用Gordon十一項健康功能型態為評估架構，藉由觀察、評估、會談及病程紀錄收集、分析資料，確立個案面臨的健康問題有：腦組織灌流失效、身體活動功能障礙及知識缺失。在護理過程中運用個別性護理措施，於急性期密切進行神經學評估、嚴密監測生命徵象、出血評估及心理支持，並把握腦中風後前六個月的黃金治療時間，鼓勵個案儘早執行床邊主動、被動全關節運動，在跨專業團隊協助與合作下，共同擬定復建計畫，幫助個案逐漸增進自我照顧能力，護理過程中持續給予個案情緒支持、給予正向鼓勵及病況相關資訊，加強個案對腦中風的認識，預防再次腦中風。2013年8月12日個案轉出至普通病房後，持續追蹤個案復健情形，並轉介出院準備服務小組，幫助個案及照顧者皆能獲得持續性照顧，使個案能維持最大肢體功能，提升其生活品質。期望藉此經驗分享，能提供護理人員對於腦中風病人之照護上的參考。

This report describes a nursing care experience of a patient diagnosed with recurrent ischemic stroke during his hospitalization in 2013. The patient received thrombolytic therapy within 3 hours of disease onset in the intensive care unit and began bedside rehabilitation in 5 days. Through observation, evaluation, interviewing, data collection and data analysis, the author used Gordon's 11-item Functional Health Patterns to assess major nursing problems. Problems included ineffective cerebral tissue perfusion, impaired physical mobility, and impaired cognition. Individual nursing care interventions in the acute phase included close monitoring of neurological status, vital signs, signs of bleeding, psychological support and early bedside active and passive range of motion exercise. The multi-disciplinary team developed coordinated rehabilitation plans that helped the patient to gradually regain self-care skills, to provide continuous emotional support, encouragement and education to prevent disease recurrence. After the 10-days ICU stay of the patient, the author continued to track the patient's progress at the medical unit regarding rehabilitation and referral to discharge planning team to ensure maximum outcome of physical functioning and quality of life. The author wishes to share this experience as a reference for future care of stroke patients.

1. Cifu, D. X.,Stewart, D. G.(1999).Factors affecting functional outcome after stroke: A critical review of rehabilitation interventions.Archives of Physical Medicine and Rehabilitation,80,S35-S39.
2. Cumming, T. B.,Thrift, A. G.,Collier, J. M.,Churilov, L.,Dewey, H. M.,Donnan, G. A.,Bernhardt, J.(2011).Very early mobilization after stroke fast-tracks return to walking: Further results from the phase II AVERT randomized controlled trial.Stroke,42,153-158.
3. Jauch, E. C.,Saver, J. L.,Adams, H. P.,Bruno, A.,Connors, J. J.,Demaerschalk, B. M.,Yonas, H.(2013).Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke,44,870-947.
4. Pollack, M. R. P.,Disler, P. B.(2002).Rehabilitation of patients after stroke.Rehabilitation Medicine,177,444-449.
5. Summers, D.,Leonard, A.,Wentworth, D.,Saver, J. L.,Simpson, J.,Spilker, J. A.,Mitchell, P. H.(2009).Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: A scientific statement from the American Heart Association.Stroke,40(8),2911-2944.
6. 何怡慧,劉秀月,黃純德(2014)。復健期腦中風病患咀嚼吞嚥障礙盛行率及初步篩檢徵象之探討。護理雜誌，61(2)，54-62。
7. 周立偉(2007)。強化腦中風預後及早復健是關鍵。中國醫訊，48，24-27。
8. 邱弘毅(2008)。腦中風之現況與流行病學特徵。台灣腦中風學會會訊，15(3)，3-4。
9. 邱明發,顏兆熊(2011)。缺血性腦中風急性期後之處置。當代醫學，38(11)，45-51。
10. 胡月娟（校閱）(2009).內外科護理學.台北:華杏.
11. 胡名霞,許書旋,李建志,王顏和,鄭建興,葉炳強(2006)。腦中風患者復健治療時程與出院及長期功能結果之關聯性。台灣醫學，10，245-255。
12. 胡漢華(2013)。胡漢華（2013）．靜脈血栓溶解劑治療急性缺血性腦中風指引2013．台北：台灣腦中風學會。
13. 胡漢華(2008).台灣腦中風防治指引.台北:台灣腦中風學會.
14. 劉雪娥（校閱）(2014).成人內外科護理.台北:華杏.
15. 衛生福利部（2013）．民國101年死因統計年報．取自http://www.mohw.gov.tw

1. 陳淑華,李淑菊(2021)。運用急性後期照顧於獨居腦中風個案照護經驗。若瑟醫護雜誌，15(1)，58-69。
2. 簡淑芬,張斐淑,丁淇平(2023)。運用多元策略提升腦中風急性後期病人自主復健運動執行率。醫學與健康期刊，12(1)，25-35。