照護一位唇顎裂青少年病患之護理經驗

The Nursing Experience of an Adolescent Patient with Cleft Lip and Palate

本文應用羅氏適應模式，照顧一位唇顎裂青少年病患之護理經驗，筆者自94年9月22日至94年10月1日期間，運用Roy理論的第一層次及第二層次評估，並加以確立問題，發現個案有恐懼、組織完整性受損、疼痛等護理健康問題。於護理過程中，應用治療性的溝通，強化病患正向行為與態度，協助個案面對自己與他人，維持口腔舒適，促進傷口癒合，緩和疼痛，期望藉此護理經驗的分享，能提供臨床護理人員照顧此類病患之參考。

This case study reported the nursing experience of a cleft lip and palate adolescent patient. During care of this patient from September 22, 2005 to October 1, 2005, the first and second level assessments in Roy’s theory were used to assess and identify nursing problems and set goals and care plans. There were three major problems including fear, impaired tissue integrity, and pain. Nursing intervention programs included therapeutic communication to enhance positive attitude, behavior, face up to oneself and another person. Patient’s mouth was maintained comfortable to promote wound healing and alleviate pain. This report provides nurses with a reference for caring similar patients in the future.