應用鼻腔通氣管於一位憩室炎術後乙狀結腸造口下陷 個案之照護經驗

Nursing Experience of Nasopharyngeal Airway in A Case of Sigmoid Colostomy Retraction after Diverticulitis

本文敘述一位憩室炎外院術後個案，經多日禁食、傷口感染、乙狀結腸造口黏 膜壞死下陷、出口處受浸潤致潮濕性皮膚炎及對醫療措施失去信心而轉入本院之護 理經驗。於 2017/4/6~4/15，運用 Gordon 十一項健康功能評估，藉由觀察、傾 聽、會談、直接照護及跨團隊討論方式，做整體性評估收集資料後，分析歸納主要 護理問題為組織完整性受損、自我照顧能力增進的準備度、焦慮。照護過程中與醫 師討論雙造口，藉由應用鼻腔通氣管連接乙狀結腸造口下陷處，以解決造口排泄問 題，教導個案雙側造口自我照顧方式，並建立互信關係減輕個案及家屬焦慮繼而恢 復對醫療措施信任順利出院。期望經由此個案照護，發揮傷造口護理師專業及創新 思維想法，提供臨床護理人員照護參考。

 

This article is talking about a postoperative female patient with diverticulitis from another hospital. She was transferred to our hospital after multiple days of fasting, wound infection, sigmoid colostomy mucosal necrosis, peristomal skin damage caused by irritant dermatitis, and no confidence in medical treatment. From April 6th to April 4th, 2017, we evaluated this patient by the assessment of Gordon 11 Function Health Patterns, through observation, listening, conversation, direct care and cross-team discussion methods, to conduct comprehensive assessment and data analysis, than we found that the main nursing problems were impaired skin integrity, the gap of readiness for enhanced stoma selfcare, and anxiety. We discussed the double stoma with the physician during the nursing period, connected a sigmoid colostomy depression with the nasopharyngeal airway to solve the problem of stoma excretion, taught her bilateral stoma self-care methods, and established a trusting relationship to reduce her anxiety and restored the family’s confidence in medical treatment. This patient was discharged smoothly, as we expected that through this nursing care experience, the professional and innovative thinking of the enterstomal therapists can be brought into practice, providing a reference for the care of clinical nurses.