照護一位成年女性膀胱癌術後身心困擾之護理經驗

A Nursing Experience of an Adult Female with Bladder Cancer suffering from Physical and Mental Distress after the Cystectomy and Ileal Conduit Surgery

癌症病人術後常因身體結構及外觀改變，產生負向情緒，導致生理、心理及社會層面面臨重大之衝擊及調適上的問題。本文描述一位40 歲女性，診斷為再發性膀胱癌第四期，接受迴腸膀胱造口留置手術，術前因為醫師未預期到腫瘤具體侵犯的範圍，未告知有造口留置的可能性，個案術後拒絕面對迴腸膀胱造口留置，擔心出院後與先生的親密關係會改變，而產生情緒低落及哭泣等情緒反應，並對未來有負向想法。筆者於2015 年11 月11 日至12 月15 日護理期間，運用傾聽、觀察、會談及羅氏適應模式進行評估及相關資料收集，確立主要健康問題：急性疼痛、身體心像紊亂、焦慮。護理過程中，生理方面藉由換藥前的疼痛評估，指導家屬肌肉按摩及轉移注意力之緩解技巧，以降低疼痛；心理方面教導調適因應技巧，給予個案及家屬支持及鼓勵，漸進式接觸迴腸膀胱造口，進而使個案接受身體外觀改變而重新學習適應，修正其負向看法，同時鼓勵案夫參與照護計畫，共同討論手術後性生活問題，澄清疑慮並建立信心，讓個案順利渡過調適的過程。建議臨床護理人員進行護理指導時可以運用圖像方式增進個案對於指導內容的理解，冀盼本文可作為日後護理人員照護類似個案之參考。

Due to change of body structure and appearance after surgery, cancer patients often expressednegative emotions and presented adjustment problems in physiology, psychological and social aspectswhen facing major shock. This article described the nursing experience of caring a 40-year-old femalewho was diagnosed with stage 4 recurrent bladder cancer and received total cystectomy and ileal conduitsurgery. The doctor did not inform the patient about the possibility of ileal bladder stoma during surgerysince he did not expect the wide-range tumor specific invasionAfter surgery, therefore, the patient wasafraid that it would impact the intimacy with her husband and fear to face ileal conduit; she felt upset,sweeping, and held more negative view of future. During the nursing period from November 11 2015 toDecember 15, 2015, the author collected the patient’s information and evaluated the main physical issueby listening, observation, face-to-face interview and applied Roy Adaptation Model; and the nursingproblems were confirmed as acute pain, disturbed body image, and anxiety.In physiological characteristics, during nursing care, we used pain assessment before wound care,trained the family members through body massage, and diverted attentions to relief patient's pain. Weinstructed the skill to adapt the situation; provided the patient and her family with nursing support andencouraged them to touch ileal bladder stoma progressively and to learn to adjust their psychologicalstatus. Through the above nursing instruction, patient started to accept and adapt her body image changeand revised the negative thinking. We also encouraged her husband to participate in the caring program,including discussing post-surgeon sexual life to clarify her doubt and to build up her confidence, andhelping her to adapt the changes of body image smoothly. We suggested that picture illustration may beused in nursing instruction to improve the patient and family members’ understanding. We expected thisnursing experience could serve as a reference for nurses taking care of similar patients.