照護一位手臂異體移植病人之護理經驗

Nursing Experience of a Received Arm Allograft Patient

10.6540/NTJN.202209_24(2).0011

彭宥慈(Yu-Cih Peng)；黃惠珠(Hui-Chu Huang)

手臂異體移植 ； 疼痛 ； 身體心像紊亂 ； arm allograft ； pain ； disturbed body image

新臺北護理期刊

24卷2期（2022 / 09 / 01）

119 - 127

繁體中文

本文是探討一位接受手臂異體移植個案之護理經驗，筆者於2018年3月21日至4月12日以連續性的照護，透過與個案互動的觀察、會談、身體評估等方式，以Gordon十一項健康功能型態進行評估，確立個案有急性疼痛、組織完整性受損及身體心像紊亂等護理問題。經與個案建立良好護病關係，藉由疼痛評估掌握其疼痛程度，提供個案喜愛的事物藉以轉移注意力，改善術後疼痛。每班觀察傷口有無感染徵象，依無菌技術予以傷口護理，衛教攝取高蛋白飲食，以促進傷口癒合，提供保護隔離預防感染。傾聽其抒發內心感受，透過病友分享經驗給予鼓勵，協助復健療程，增強個案信心並願意配合，讓異體移植發揮最大功能。因手臂移植臨床案例較少，臨床實務建議增設視聽教材，以提升其注意力並加深印象，希望藉由此文，作為醫護人員照護此類病患之參考。

This article is discussing the nursing experience of a case who received arm allograft. From March 21 to April 12, 2018, the author cared for the patient with interactive observation, conversation, physical assessment, and other nursing methods. Through Gordon 11 Function Health Patterns evaluation, the patient had medical problems such as acute postoperative pain, impaired tissue integrity, and disturbed body image. By assessing the pain score and establishing well relationship with the patient, the author provided the patient's favorite things to turn his attention away and improve postoperative pain. The nursing team closely observed infection signs of surgical wounds, used aseptic techniques on wound care, and encouraged the patient to ingest high-protein diet which could promote wound healing and increase protection against infection. By listening to the patient inner feelings, sharing similar experience from other patient, assisting in the rehabilitation process, strengthening the patient's confidence, and encouraging to cooperate, the arm graft could maximize its function. The addition of audio-visual learning materials is also recommended to enhance patient attention and deepen their impressions. Due to few cases of arm transplantation, we hope to share the nursing experience of clinical practice for these patients.

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