照顧一位天?瘡患者之護理經驗

The Nursing Experience of a Patient with Pemphigus

天?瘡是一種侵犯皮膚黏膜，產生自體免疫水泡性疾病。罹患此病易導致皮膚損傷、口咽潰瘍、疼痛、活動受限、感染以及敗血症而死亡。本文是描述照顧一位患有天?瘡病患，因口腔黏膜與全身皮膚破損而住院的護理經驗。護理期間自90年10月6日至91年2月7日，藉由觀察、會談及身體評估收集資料，並以Gorden十一項健康性功能型態評估，確立個案主要護理問題有：急性疼痛、皮膚完整性受損、營養不均衡：少於身體所需、身體心像紊亂等。筆者在四個月的照護過程中，給予合宜的護理措施，緩解個案疼痛並促進傷口癒合，改善患者營養狀況；並透過陪伴、溝通及傾聽等技巧，建立良好的治療性關係，使個案能接受疾病所造成的身體心像改變；家屬學會照護的患者日常生活的技能，希望能藉此護理經驗，提供日後照顧此類病患之參考。Pemphigus is an autoimmune blistering disease. It may cause skin damag, oropharyngeal ulcerations, pain, limiting the patient's daily activities and sepsis. The aim of this article was to discribe the nursing experience of caring a patient with pemphigus complicated with vesicles, bulla and damage of skin and mucous membrane. The nursing care duration was from October 6, 2002 to February 7, 2003. The primary nurse used clinical observation, interview and physical assessment guided by the Gordon 11-iteam Functional Health Pattern to identify the patient’s major health problems. There were four major nursing diagnoses which were acute pain, impaired skin integrity, imbalanced nutrition/less than body requirements, and disturbed body image. Then the nurse designed many nursing interventions based on the patient's health problems to relieve the patient’s pain, to avoid skin further injury,to improve nutrition status and to promote physical comfort. During caring period, we finally gained good therapeutic relationship between the nurse and the patient. Therefore nurse helped the patient accept the changes of body image and also teach the caregiver how to deal with patient's daily care. This experience was presented to our fellow nurses as a persuasive example.