協助一位唇顎裂青少女接受正顎手術之個案管理經驗

本文運用個案管理模式協助一位唇顎裂青少女面對正顎手術之護理經驗。期間自2020年08月10日至2020年09月07日，涵蓋門診、住院、返家休養與回診追蹤等連續性照護。
運用羅式理論作為護理評估模式，藉由觀察、會談、身體評估和電話訪談收集資料；確立個案有焦慮、組織缺損以及營養少於身體所需等健康問題。筆者展現顱顏個案管理師整合與協調的功能，初期與個案建立治療性人際關係，發現問題並回饋團隊討論解決方法，個案賦能為導向遂參與醫療決策，應用多媒體線上影音教材及行動應用程式輔以指導。建議護理人員能協助唇顎裂青少年參與醫療自主權，增進自我概念與自我控制感。藉此護理經驗分享提供日後個案管理之參考。

In this article, we detail our nursing experiences using a case management model to care for a female adolescent with cleft lip and cleft palate who underwent orthognathic surgery. This comprehensive care spanned outpatient clinic visits, hospitalization, home recuperation, and subsequent follow-up from August 10, 2020, to September 7, 2020. Employing Roy's adaptation model theory as our nursing assessment framework, we collected data through observation, interviews, physical assessments, and telephone interviews. The results confirmed several health issues, including anxiety, tissue defects, and undernutrition. We, as authors, exemplified the integrated and coordinated functions of a craniofacial case manager. Initially, we established a therapeutic interpersonal relationship with the patient, identified problems, provided feedback to the team, and actively participated in discussions to address these issues. We guided the patient in medical shared decision-making with an empowerment-oriented approach and facilitated self-care education using multimedia online audio-visual teaching materials and mobile apps. We advocate for nursing specialists to assist adolescents with cleft lip and palate in participating in shared medical decision-making processes to promote their medical autonomy, enhance self-concept, and improve self-control. Through sharing our nursing experiences, we aim to provide valuable references for future case management initiatives in similar cases.