1例96岁超高龄急性脑梗死合并股骨粗隆间骨折多病共存患者的MDT康复及人文护理

MDT-Based Rehabilitation and Humanistic Nursing for a 96-Year-Old Super-Elderly Patient with Acute Cerebral Infarction Complicated by Femoral Intertrochanteric Fracture and Multiple Comorbidities

摘要: 目的：总结1例96岁超高龄患者同时发生急性脑梗死与右股骨粗隆间骨折、并发重症肺炎等多病共存的多学科协作(Multidisciplinary Team, MDT)康复护理经验，探讨超高龄危重患者的护理难点与人文照护策略。方法：对1例96岁男性患者，组建由老年科、神经内科、骨科、呼吸与危重症医学科、康复医学科、临床药学、营养科及专科护理团队组成的MDT小组，开展老年综合评估，针对急性脑梗死与骨折骨牵引制动的治疗矛盾、反复误吸所致重症吸入性肺炎、导管相关血栓与消化道出血并存的抗凝风险、重度营养不良以及患者厌世拒治心理危机等问题，实施集束化并发症防控、分阶段康复训练、个体化营养支持与系统性心理人文干预。结果：经108天住院期间多学科联合干预，患者重症肺炎、吸入性肺炎得到控制，呼吸衰竭纠正，消化道出血停止，颈内静脉导管周血栓病情稳定；患者由情绪低落、拒绝全部治疗转为主动配合诊疗；拆除骨牵引后循序渐进开展康复锻炼，出院时右下肢肌力恢复至3-级，其余四肢肌力达4级，精神良好，进食无呛咳，患者及家属对诊疗护理过程高度认可。入院–出院关键评估指标对比显示，Barthel指数、肢体功能、疼痛、营养、吞咽等多项指标均得到明显改善。结论：对96岁超高龄多病共存危重患者，MDT模式可有效平衡多重治疗矛盾、降低卧床相关严重并发症；在躯体治疗的同时重视心理危机干预与人文关怀，能帮助患者重建治疗信心、最大限度保存躯体功能、改善生存质量，值得在同类超高龄复杂病例中推广。

Abstract: Objective: To summarize the rehabilitation nursing experience of multidisciplinary team (MDT) for a 96‑year‑old super‑elderly patient suffering from concurrent acute cerebral infarction, right femoral intertrochanteric fracture and complications such as severe pneumonia, and explore the nursing difficulties and humanistic care strategies for critically ill super‑elderly patients. Methods: For a 96‑year‑old male patient, an MDT group was set up, which consisted of geriatrics department, neurology department, orthopedics department, respiratory and critical care medicine department, rehabilitation medicine department, clinical pharmacy department, nutrition department and specialized nursing team. Comprehensive geriatric assessment was carried out. Aiming at the therapeutic conflicts between acute cerebral infarction and skeletal traction immobilization for fracture, severe aspiration pneumonia induced by repeated aspiration, anticoagulation risks caused by coexistence of catheter‑related thrombosis and gastrointestinal bleeding, severe malnutrition, as well as the patient’s psychological crisis of world‑weariness and refusal to treatment, bundle‑based complication prevention and control, phased rehabilitation training, individualized nutritional support and systematic psychological and humanistic intervention were implemented. Results: After 108‑day multidisciplinary joint intervention during hospitalization, the patient’s severe pneumonia and aspiration pneumonia were controlled, respiratory failure was corrected, gastrointestinal bleeding stopped, and the condition of internal jugular catheter‑related thrombosis remained stable. The patient shifted from low mood and refusal of all treatments to active cooperation with diagnosis and treatment. Gradual rehabilitation exercises were performed after skeletal traction removal. At discharge, the muscle strength of the right lower limb recovered to grade 3‑, and the muscle strength of the other limbs reached grade 4. The patient was in good mental condition without choking while eating. Both the patient and his family highly recognized the diagnosis, treatment and nursing process. The comparison of key assessment indicators on admission and discharge showed that multiple indicators including Barthel index, limb function, pain, nutrition and swallowing were significantly improved. Conclusion: For critically ill 96‑year‑old super‑elderly patients with multiple comorbidities, the MDT model can effectively balance multiple therapeutic contradictions and reduce severe bed‑rest‑related complications. While providing physical treatment, emphasis on psychological crisis intervention and humanistic care can help patients rebuild confidence in treatment, preserve physical function to the maximum extent and improve quality of life, which is worthy of popularization in similar complex super‑elderly cases.