照顧一位下肢撕裂傷行分層皮膚移植手術後之護理經驗

Nursing Experience of Lower Extremity Skin Tear Patient with Post Split Thickness Skin Graft Surgery

10.6692/KJN-2013-30-2-7

許世玉(Shih-Yu Hsu)；李慧琦(Hui-Chi Li)；林佑樺(Yu-Hua Lin)；李靜芳(Ching-Fang Li)

皮膚撕裂傷 ； 分層皮膚移植手術 ； 傷口照護 ； 疼痛 ； 焦慮 ； skin tear ； split thickness skin graft surgery ； wound care ； pain ； anxiety

高雄護理雜誌

30卷2期（2013 / 08 / 01）

72 - 83

繁體中文

本文係探討一位75歲女性因車禍導致右小腿嚴重撕裂傷並接受分層皮膚移植之術後照護經驗。筆者在護理照護中運用Gordon十一項健康功能型態進行整體性護理評估，並以觀察、會談、身體評估及文獻查證方式收集資料。護理期間自2011年7月16日至2011年7月23日。確立主要問題有組織完整性受損、手術後傷口疼痛及焦慮護理問題。筆者經由與個案及照顧者建立良好護病關係，配合文獻給予個案分層植皮手術後傷口照護與指導，以預防傷口感染並使個案對傷口照護有初步的認識與了解。教導個案疼痛緩解技巧以減輕手術後傷口不適，並鼓勵個案說出心理感受，促進自我照顧能力，以降低手術後的不確定感。希望藉由此經驗分享，提供照護此類個案之參考。

This article is to report the case of post-surgery nursing care for a patient with right lower extremity skin tear who underwent split thickness skin graft surgery. Gordon functional health assessment was used in this case report. Observation, interview, physical assessment approach and literature review were used to collect and analyze data from July 16th to 23rd, 2011. Three problems of the patient were identified: (1) Impaired tissue integrity; (2) Pain of post surgery; and (3) Anxiety. Nursing activities carried out include: established relationship with patient and care givers, coordinated literature of split thickness skin graft wound caring and provided wound care education to prevent wound infection and improve patient's knowledge about wound care; provided pain-relief education for the patient and family to relieve discomforting pain, encouraging expressing the ”in-heart” feeling, improving self-care ability to decrease feelings of uncertainty. It is hoped that the nursing experience in this case can serve as a reference for nursing professionals in providing nursing care for this kind of patient.