照顧一位皮膚癌合併惡性蕈狀傷口病人的護理經驗

Nursing Experience of a Skin Cancer Patient with Malignant Fungating Wound

本文探討一位皮膚癌併發惡性腫瘤蕈狀傷口個案的護理經驗。護理期間自2010年1 月31 日至2 月20 日，運用Gordon十一項功能型態評估，確立個案護理問題有：疼痛、組織完整性受損、身體心像紊亂及無望感。護理過程中藉由傷口照護技巧以控制滲出液、惡臭與出血情形，維持身體舒適及提供調過技能協助其身體心像重建統合；以主動、同理心關懷，建立護病信任關餘，進而評估個案與家屬的出院準備需求，協調居家照護資源，使個案順利出院返家，接受居家安寧照護，獲得身、心、靈的滿足。The case study is to explore the nursing experience of a skin cancer patient with malignant fungating wound. The duration ofnursing care was ftom January 31st to February 20th, 2010. Gordon's Functional Health Pattems were used to assess the patient. The following nursing issues were identified: pain, impaired tissue integrity, body image disturbance, and hope1essness. We provided quality wound care in controlling wound odor, exudate, and b1eeding to maintain the patient's physical comfort. We a1so provided coping skills to reconstruct the patient's self-esteem and body image. We took an active approach to providing empathy and building a trusting patient-nursing relationship. We further assessed the patient's and family's needs of discharge planning, and coordinated the resources of home care. Finally, the patient was discharged and went home smooth1y, received hospice home care, and achieved the physical, psychologica1, and spiritua1 satisfaction.