一位惡性蕈狀傷口合併腸皮瘻管個案之護理經驗

Nurse's Experience Caring for a Patient with Malignant Fungating Wound with Enterocutaneous Fistula

文呈現照護一位大腸癌末期因癌細胞擴散，於右腰形成惡性蕈狀傷口，且合併腸皮瘻管之個案護理經驗。護理期間為2006年4月22日至6月25日，經由Gordon的十一項評估進行資料收集，確認個案健康問題為慢性疼痛、睡眠型態紊亂、組織完整性受損及身體心像紊亂。由於本文著重腸皮瘻管的照護，故僅分享組織完整性受損之護理過程，筆者與醫療團隊經由腦力激盪與創新，應用各種方式，改善糞便持續滲漏至傷口與臭味的問題，以促進個案的舒適與改善生活品質，更協助患者完成心願，安詳走完人生最後的旅程，本照護經驗可提供臨床照護類似個案時的參考。

This report describes a nurse's experience treating a metastatic skin lesion with draining enterocutaneous fistula located in the right posterolateral abdomominal wall. The period of nursing care ran from April 22th through June 25th, 2006. In studying the nursing process, Gordon's assessment tools were used to gather subjective and objective data to establish critical care issues, which included chronic pain, sleep pattern disturbance, impaired tissue integrity, and disturbed body image. The focus of care was to manage the pain and irritation caused by the fistula of enterocutaneous. Targeting the issue of impaired tissue integrity, we developed and applied various methods to decrease the wound macerated from fecal, control odor, maintain patient comfort and improve patient quality of life. We helped the patient achieve her wish to end her life in peace. This nursing experience may provide a reference in caring for such cases in the clinic.