愛看護理記錄的病房主任

As a Nursing Records Reading Lover Ward Chief

本文敘述照顧一位54歲男性罹患口腔癌復發，再次接受口顎皮瓣重建手術的護理經驗，接受口顎皮瓣重建手術後，大多會面臨生、心理改變之多重衝擊，運用Gordon十一項健康功能型態進行護理評估，於2014年4月21日至5月10日確立主要健康問題有：組織完整性受損、急性疼痛、身體心像紊亂、個人因應能力失調，護理期間針對病患之個別性擬訂護理計畫，提供充份疾病及術後傷口衛教、依病人疑問予詳盡的解釋，減少其焦慮；採持續性的關懷、傾聽並以同理心的態度及給予正向鼓勵引導表達內心感受，來面對顏部外觀的改變。希望能藉此護理過程之經驗分享，提供護理同仁日後照顧此類個案之參考，能給予更適切的護理。

The article described a nursing experience of a 54-year-old male oral cancer patient receiving repeated maxillofacial reconstruction after relapse. Most patients receiving maxillofacial reconstruction would face the combined impact of physical and psychological changes. The nursing period lasted from April 21^(st) to May 10^(th), 2014. By applying Gordon's 11 functional health patterns for a comprehensive nursing assessment, the following health problems were established: impaired tissue integrity, acute pain, body image disturbance, and ineffective individual coping. During the nursing period, an individualized care plan was developed for the patient to provide adequate disease and wound care education, and detailed explanation to address the patient's inquiries to ease his anxiety. A continuous care, listening, and empathy were used to encourage the patient to express his inner feelings in order to face change to the patient's appearance. We hope the nursing experience can serve as a reference for other nursing staff when attending to patients in similar conditions.