照顧一位血液透析病人因慢性骨髓炎面臨可能再次截肢之護理經驗

Caring for a Hemodialysis Patient Facing Possible Amputation due to Chronic Osteomyelitis

本文描述一位血液透析病人因右腳踝反覆骨髓炎與壞死性筋膜炎住院治療多次，歷經反覆感染清創，面臨可能再次截肢之苦，造成身心衝擊之照護經驗。於2019年6月22日至2019年7月28日血液透析照護期間，以直接照護、觀察、會談及病歷查閱方式收集資料，運用Gordon十一項健康功能進行整體性評估，確立個案有現存危險性感染、營養少於身體需要及無望感護理問題。護理過程中，透過製作換藥步驟單張及錄製正確換藥影片，教導傷口自我照護技能與知識，改善感染問題，促進傷口癒合。利用食物模型教導正確攝取足夠的蛋白質及熱量，讓個案瞭解營養攝取對傷口的重要性；請營養師依個案喜好設計豐富多元的餐點；衛教採少量多餐，使個案增加進食量，攝取足夠營養。透過主動關懷、陪伴，鼓勵個案表達感受；提供疾病相關訊息，鼓勵參與復健計畫；參與病友社群團體，藉由分享經驗、抒發情緒，增強社會支持；提升正向態度，積極面對治療，改善無望感。建議在照護過程中，以病人為中心，教導正確照護技巧，瞭解疾病資訊及治療方案，讓病人對治療擁有選擇自主權，進而解決生理及心理問題。

This article describes the nursing care experience of a hemodialysis patient hospitalized for recurrent osteomyelitis and necrotizing fasciitis of the right ankle. After recurrent infection and debridement, he faced the physical and mental shock of possible re-amputation. While the patient received hemodialysis care between June 22, 2019 and July 28, 2019, data were collected through direct care, observation, interviews, and review of medical records. Gordon's 11 functional health patterns were used for holistic assessments to confirm that the patient was not currently suffering from a dangerous infection, not receiving less nutrients than the body required, and receiving care for feelings of hopelessness. During the nursing care process, pamphlets and recordings describing the steps for changing dressings were made available to the patient, and the patient was taught the skills and knowledge necessary for wound self-care, thereby improving infection and promoting wound healing. Food models were used to instruct the patient on proper intake of adequate protein and calories in order to emphasize the importance of nutritional intake for wound healing. A nutritionist designed rich and diverse meals based on the patient's preferences. A health educator used a small number of meals to increase the amount of food the patient consumed and ensured that he received enough nutrition. The patient was encouraged to express his feelings through active care and companionship. Furthermore, the patient was provided information related to the disease and encouraged to participate in rehabilitation programs and patient support groups to enhance social support by sharing experiences and expressing emotions. Positive attitudes were improved, and treatment was framed effectively, thereby improving feelings of hopelessness. We recommend patient-centered care, educating the patient in proper selfcare skills, and ensuring understanding of the disease and its treatment plans so that patients have the autonomy to select their own treatment, thereby addressing their physical and psychological challenges.