| 中文摘要 |
本篇報告描述照顧一位食道弛緩不能症已婚35歲女性個案之護理經驗。照顧期間為2010年8 月2 日至8 月24日，筆者運用Gorden十一項健康功能型態評估為架構，經由直接觀察、身體評估、傾聽及會談等方式，對病人進行身體、心理、社會等方面整體性評估，完成相關資料的收集。發現病人有：（一）營養少於身體需要，與攝入之營湊不足以滿足身體需求之狀況；（二）潛在危險性成染與手術傷口有關； （三）急性疼痛與術後傷口有關；（四）焦慮與術後傷口滲漏及未知的病程進展有關等健康問題。於照護過程中，除滿足病人生理需求，亦透過病人與家屬建立良好的治療性關係，提供心理支持及照護，促使病人能由口進食少量流質飲食，並且增加熱量的攝取、術後傷口無感染發炎、傷口疼痛緩解，且自訴對術後復原情形逐漸有信心，尤其是在提供系統性衛教指導後，病人之焦慮、程度有明顯減輕，故期望藉由照顧此位食道弛緩不能症之外科術後病人的護理經驗，能提供護理同仁於臨床照護此類病人之參考。The paper is targeted at the caring experience of a 35 year-old married female who suffered from achalasia. The author took care of the patient from August 2th to August 24th in 2010. Based on the Gordon's Model, the data were collected by means of observation, interviews, and physical assessment during the nursing process. The patient's health problems were identified as poor nutrition in the body, potential infection related to surgical wound, acute pain related to surgical wound, and anxiety related to wound leakage with uncertain diseases. During the nursing process, the author attempted to build up a good therapeutic interaction with the patient and his family in a caring way. The patient who can take small amounts of liquid diet orally can increase the calories intake after the nursing care. In addition, the patient's surgical wound was clean without any signs of inflammation and the pain score decreased. The patient described that she had confidence to face the surgical wound and her anxiety alleviated after being provided with postpartum discharge instructions. The author hoped to provide her nursing experience to other nurses about the caring experience of this patient. |
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