照顧一位頭皮撕脫傷個案之護理經驗

Experience of Nursing Care in a Patient with Scalp Avulsion Injury

10.3966/102673012017122804013

鄭佩芬(Pei-Fen Cheng)；陳麗月(Li-Yueh Chen)；翁芝棋(Chih-Chi Weng)

頭皮撕脫傷 ； 創傷 ； 身體心像紊亂 ； scalp avulsion injury ； trauma ； disturbed body image

長庚護理

28卷4期（2017 / 12 / 01）

720 - 728

繁體中文

頭部及顏面損傷個案接受整型重建手術後，需面臨生、心理改變之多重衝擊，並影響到個案日後的社會交際與日常生活，顯示住院期間傷口照護及心理支持之重要。本文描述一位40歲女性，因工作時頭髮不慎被機器捲入，造成頭皮撕脫傷之護理經驗。筆者於2016年1月2日至1月15日，運用會談、觀察、傾聽及病歷查閱等方式收集資料，並以Gordon十一項健康功能型態進行個案生理、心理、社會及靈性整體性評估，確立主要健康問題有：組織完整性受損、現存性感染及身體心像紊亂，護理期間針對個案之個別性擬訂護理計畫，術後一天3至4次積極的換藥治療，並於換藥時嚴格遵守無菌技術、每日每班觀察傷口癒合情形並與醫師討論換藥方式；提供充份衛教、執行照護時給予告知及詳盡的解釋，減少其焦慮；採持續性的關懷、傾聽並同理個案感受及給予正向鼓勵引導表達內心想法，以面對身體外觀的改變。期望能藉此護理過程之經驗分享，以提供護理同仁對日後照顧此類個案有更多的照護知識及技巧，並給予適切的護理。

Patients with injury to head and face usually need to face multiple physical and psychological impacts due to changes in social communication and daily life after a reconstruction surgery. Thus, wound care and psychological support during the hospitalization are important. This article described the experience of nursing care on a 40-year-old woman who had a scalp avulsion injury after her hair being trapped into a machine. The patient's data were collected by conversation, observation, listening, and reviewing the medical records from January 1 to 15 in 2016. Furthermore, Gordon's 11 Functional Health Patterns were used to assess the patient’s integrity regarding physiological and mental health, sociality, and spirituality. The main health problems identified included impairment of the skin integrity, existed infection, and disturbance of body image. An Individualized nursing plan was developed, including changing the dressing with aseptic technique 3-4 times a day, , daily inspecting the healing progress, and discussing appropriate wound care method with the doctor. Moreover, a complete patient instruction and detailed explanation were provided to reduce the anxiety of the patient. In addition, a persistent care, listening, and empathetic altitude were provided to encourage the patient to share her emotion and to face the change of her appearance. We anticipated the experience of nursing care could provide a reference for the nursing staff to care similar patients.

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