照顧一位游離肌肉皮瓣重建手術失敗個案之護理經驗

Postoperative ICU Nursing Experience Caring for a Young Woman After a Failed Free Muscle Flap Reconstruction Surgery

本文為游離肌肉皮瓣重建手術失敗個案之護理經驗，照護期間2016年2月19日至2月28日，藉由傾聽、觀察及會談技巧，運用Gordon十一項功能性健康型態評估為指引，收集主、客觀資料，發現個案有疼痛、組織完整性受損、焦慮及身體活動功能障礙等護理問題。藉由建立良好護病關係，運用音樂及電視轉移注意力緩解疼痛、執行傷口照護並評估皮瓣變化、提供皮瓣重建資訊、鼓勵表達自身想法，透過衛教及心理支持，緩解其焦慮情緒，並了解重建手術失敗之感受，幫助其面對及調適，以正向態度面對治療；游離肌肉皮瓣觀察重點在於肌肉濕潤度、血流情形及顏色，一旦發現異常立即通報給予醫療處置，可增加重建成功率，期望藉此經驗提供臨床護理人員參考，以提升照護品質。 This paper describes a postoperative ICU nursing experience caring for a young woman after a failed free muscle flap reconstruction surgery. The nursing period lasted from February 19th to 28th, 2016. Using Gordon’s functional health patterns as the framework for assessment, the author collected data by observing and interviewing the patient, and identified the following nursing problems: acute pain, impaired tissue integrity, anxiety, and impaired physical mobility. The author used individualized nursing care, applied a pain observation tool to document the patient’s pain and relief discomfort, monitored flap blood flow to ensure the prevention of graft failure, and built trust with the patient through care to facilitate a positive patient attitude. Free muscle flap observation is different from that of skin flaps. It should focus on the observation of muscle moisture, blood flow, and color. In addition, immediate notification of medical treatment can increase the success rate of reconstruction. It is hoped that the sharing of this experience can be used to provide a reference for clinical nursing personnel to improve the quality of clinical care.