Tanaka Yuko, Ohori Yoko, Seshimo Akiyoshi
Gan To Kagaku Ryoho. 2013 Dec;40 Suppl 2:219-20.
A discharge planning nurse at an acute care hospital conducted discharge planning for an elderly person with dementia who is in his/her 90s and his/her family. The nurse was involved in the choice of nutrition management method and was able to support the family's decision-making. The family had high expectations for oral ingestion, and there was disparity between those expectations and the actual state of the disease, in which aspiration occurred frequently. The nurse respected the family's wishes, but also helped the family to correctly understand the state of the disease and to make satisfactory choices about future daily life. In order to guarantee safety, the discharge planning nurse held a conference with people related to homecare, such as the home-visiting physician, the home-visiting nurse, and the care manager. As a result of the conference, that family was able to feel satisfied with and choose gastrostomy as the nutrition method. The current situation was better understood because information was shared with the community, and the confidence in the community was strengthened by giving consideration to the family's burden. It was reconfirmed that the cooperation of local staff members is useful in discharge planning.
一家急症护理医院的出院计划护士为一位90多岁患有痴呆症的老人及其家人制定出院计划。该护士参与了营养管理方法的选择，并能够支持家庭的决策。家人对经口摄入寄予厚望，而这些期望与疾病的实际状况存在差距，即频繁发生误吸。护士尊重家人的意愿，但也帮助家人正确了解疾病状况，并对未来的日常生活做出满意的选择。为确保安全，出院计划护士与家庭护理相关人员，如上门医生、上门护士和护理经理，召开了一次会议。会议结果是，那个家庭能够对胃造口术作为营养方法感到满意并做出选择。通过与社区共享信息，更好地了解了当前情况，并且通过考虑家庭负担增强了社区的信心。再次确认当地工作人员的合作在出院计划中是有用的。
