照護口腔癌併腫瘤蕈狀傷口病患之護理經驗

The Nursing Experience for a Patient with Oral Cancer and Malignant Fungating Wounds

10.3966/102673012015062602007

林怡君(Yi-Chun Lin)；陳淑真(Shu-Chen Chen)

口腔癌 ； 腫瘤蕈狀傷口 ； 羅氏適應理論 ； oral cancer ； malignant fungating wound ； Roy' adaptation model

長庚護理

26卷2期（2015 / 06 / 01）

192 - 202

繁體中文

口腔癌常伴隨疼痛及難癒合之蕈狀傷口。本篇為探討一位口腔癌合併腫瘤蕈狀傷口之病患，護理期間於2012年12月10日至2013年1月12日止，筆者運用羅氏適應模式理論為評估架構，利用觀察、筆談、家屬會談、身體評估、直接照護等方式進行資料收集與分析，確立病患護理問題有慢性疼痛、組織完整性受損、身體心像紊亂及無望感等。護理過程中，藉由提供舒適環境減緩病患疼痛情形，教導淨化呼吸法和漸進式肌肉放鬆法於換藥時轉移注意力，使病患達到放鬆功效，並適時評估傷口變化，教導適當擺位以避免組織受壓迫而影響血循，並利用傾聽方式了解病患對傷口導致身體心像改變的感受，增加對自我照顧的參與感，並正向面對傷口，藉此經驗分享，期望能提供護理人員在照護上之參考。

Oral cancer is commonly associated with pain and fungating wounds. Thus, providing patients with approaches to mitigate this condition is necessary. This study investigated a patient with oral cancer and comorbid fungating wounds. The patient received nursing care between December 10, 2012 and January 12, 2013. This study implemented the Roy's adaptation model as an evaluation framework, collecting and analysing data based on various methods (e.g., observations, written communication, interviews with family members, physical evaluations, and direct care) to determine problems of the patient, such as chronic pain, impaired tissue integrity, body image disturbances, and feelings of hopelessness. During the process of nursing care, we furnished a comfortable environment for the patient to alleviate their pain. In this environment, the patient was taught sudarshan kriya practices and progressive muscle relaxation methods, in order to divert his attention and relax him during dressing changes. In addition, we performed timely assessments of variation in the wound, taught the patient appropriate positioning to avoid applying pressure to tissues and hindering blood circulation. By listening to the patient's concerns, we determined the patient's feelings regarding changes in body image resulting from the wounds, willingness for selfcare, and positivity toward wound conditions. Through experience sharing, this study expects to provide nurses with a nursing care reference.

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