A Nursing Experience for a Patient with Cerebral Vascular Accident in Emergency Department

[[abstract]]本文敘述一位79歲男性腦中風病患於急診室求診之護理經驗，筆者以羅氏適應模式爲評估工具，透過觀察、身體評估及電訪等收集資料，確立個案有呼吸道清除功能失效、潛在危險性皮膚完整性受損及身體活動功能障礙等健康問題。筆者配合醫療措施執行護理協同性功能外，運用個案在急診有限的護理期間發揮良好治療性溝通，衛教主要照顧者與個案有關之照護技能，配合討論及回覆示教等方式，提供主要照顧者與個案疾病相關居家照護資訊。筆者將此個案護理經驗提出分享，盼能做爲日後照護類似個案參考。 This article describes a nursing experience for a 79-year-old patient with cerebral vascular accident in the emergency department. The author applied Roy's Adaptation Model for patient assessment. Data were collected through patient observation, physical examination, and patient interview via phone. The three identified major health problems were ineffective airway clearance, potential risk for impaired skin integrity, and impaired mobility. Besides working with other disciplines for the patient's medical problems, the author established a therapeutic relationship with the patient and family members. This facilitated patient education on the subject of home care. Discussion and a demonstration of skills were included during the teaching. This article can be used as a reference for nurses who care for stroke patients in the emergency setting