一位學齡期兒童於開心手術後經歷身體心像改變的適應過程

A Study of the Process by Which a School-Age Child Adapted to Body Image Changes Following Open-Heart Surgery

本文探討一位學齡期兒童因罹患先天性心室中膈缺損，於開心矯正手術後經歷身體心像改變的適應過程。筆者與個案建立信任關係後，運用無創傷性照護理念及各種投射性溝通技巧、會談、行為觀察、說故事及遊戲等方式，發現個案在開心手術後有「身體心像紊亂」的護理問題，經歷下列四個階段的適應過程：(1)衝擊期：疑問、做錯事被處罰的疾病認知、失落及憤怒；(2)退卻期：否認、焦慮、退縮及逃避社交接觸、自卑；(3)承認期：認知改變、主動參與、未來導向之關注；(4)重建期：產生正向自我心像、重組新的身體心像。護理措施朝向提供個案較多知覺迴饋及正增強的機會，協助確認情境的正向觀點並重新建構開刀的意義，增強其社會支持系統，以提昇自信心、自尊及自我價值感，終能接受開刀傷口為「勇敢」的象徵，準備重返學校及回歸正常化的生活。此結果可提高兒科護理人員察覺兒童身體心像改變的敏感度，設計多元化的護理措施來滿足不同的適應階段的需求。此種以身體心像改變為導向的照護模式有助於重建身體心像的整合狀態，可作為未來兒科護理的重要架構。

This case report attempts to explore the adaptive process of body image changes in school-age children suffering from congenital ventricular septal defect (VSD) following open-heart surgery. After establishing trust relationship, we applied atraumatic care, projective communication techniques, interviews, behavioral observation, storytelling and play in our interaction with that child. We found the child experienced ”body image disturbance” after open-heart surgery and underwent a four stage adaptive process as follows: (1) Impact (questioning, perception of punishment for wrongdoing, loss, anger); (2) Retreat (denial, anxiety, withdrawal, escaping social contact, inferiority); (3) Acknowledgment (cognitive change, active participation, future-oriented concerns); and (4) Reconstruction (positive self-image, reconstructing body image). Nursing intervention provided the case with more opportunities for sensory feedback and positive reinforcement and also assisted the patient to adopt a positive view of the situation and then to reconstruct and realize the meaning of such surgery. We reinforced the social supporting system to promote self-confidence, self-esteem, and self-value. The child finally accepted the wounds resulting from the operation as a symbol of ”bravery”; a breakthrough likely to help in the child's re-entrance to school and normalization of life. Study findings both enhanced pediatric nurse understanding of the adaptive process involved in body image change and provided knowledge essential to designing flexible-option nursing interventions tailored to meet the demands of different adaptation stages. Obviously, such a caring model designed to meet the differing needs of different body image changes has the potential to benefit of body image integration greatly and can provide the pediatric nursing framework in the future.