照護一位下肢靜脈潰瘍困難傷口病人之護理經驗

Nursing Care Experience of Patients with Leg Venous Ulcer Problems

本文旨在探討一位下肢靜脈潰瘍困難傷口病人，因左足踝傷口久未痊癒之護理經驗，於2020年9月17日至2020年12月29日期間，運用Gordon十一項健康功能評估工具收集資料，發現個案有「皮膚完整性受損」、「知識缺失」、「焦慮」等三個主要健康護理問題。護理過程中，運用抗生物膜纖維敷料，教導正確的傷口照護方式，及搭配高蛋白飲食，以利傷口癒合，教導持續穿著加壓彈性繃帶的重要性，並執行抬腿及小腿後側肌肉伸縮運動，以避免下肢靜脈潰瘍惡化，藉由建立良好護病關係，讓個案參與醫療決策權，並運用音樂治療於換藥過程中，提升治療及照護的參與度，以減輕其焦慮及正向因應傷口進程。建議可製作介紹下肢靜脈潰瘍的影片、敷料特性的實體圖卡、彈性襪選擇及穿脫影片，以及日常生活保養知識的輔助單張或影片，以利下肢靜脈潰瘍病人及家屬返家後學習自我傷口照護，進而提升整體照護品質。

This article outlines the nursing care experience of a patient with leg venous ulcers’wound complications. The patient experienced persistent wounds on the left ankle for seven months following a laser and saphenous vein resection operation. The nursing care duration spanned from September 17, 2020 to December 29, 2020. The assessment of nursing problems utilized Gordon’s functional health assessment guide, identifying issues such as skin integrity impairment, a lack of care knowledge, and anxiety. Throughout the care period, the author administered anti-biomembrane (biofilm) fiber dressings, provided education on wound care techniques coupled with a high-protein diet to facilitate wound healing. The emphasis was placed on the importance of continuous use of compression elastic bandages and leg muscle contraction exercises to prevent the deterioration of lower limb venous ulcers. By establishing a robust nursing relationship, we provided the patient with medical decision-making power. Music therapy was incorporated into the dressing change process to enhance treatment participation and alleviate anxiety. Thus, it is recommended to create auxiliary leaflets or videos covering topics such as an introduction to venous leg ulcers, dressing characteristics, selection of elastic stockings, and daily maintenance knowledge. Assistance to the patient and their families in early home care is advocated, providing them with self-care techniques for an enhanced overall quality of care.