運用羅氏適應模式照護罹患乳癌併蕈狀傷口病人之護理經驗

A Nursing Experienc of Applying Roy's Adaptation Moedl to a Patient with Fungating Wound of Breast Cancer

10.6880/TJON.202406_24(1).07

蕭語彤(Yu-Tong Xiao)；游馥蓮(Fu-Lien Yu)

乳癌 ； 惡性蕈狀傷口 ； 身體心像紊亂 ； 疼痛 ； breast cancer ； malignant fungating wound ； body image disturbance ； pain

腫瘤護理雜誌

24卷1期（2024 / 06 / 01）

79 - 88

繁體中文;英文

本文為一位48歲女性乳癌併蕈狀傷口及骨轉移之護理經驗。個案於2019年確診乳癌1期，因故延誤治療，再次就醫時乳房腫瘤潰爛出血，右下肢骨轉移且肌力退化，造成身體外觀改變、行動不便及出現負面情緒，引發筆者探討。護理期間為2022年3月20日至27日，筆者藉由身體評估、持續照護、會談及觀察等方式收集主客觀資料，透過羅氏適應模式評估確立疼痛、組織完整性受損與身體心像紊亂等健康問題。照護期間以轉移注意力、肢體支撐及藥物處置等方式進行疼痛控制；協助換藥時挑選合宜的敷料減少傷口異味及滲出液；提供鮮豔絲巾轉移對於傷口焦點，藉主動關懷及陪伴，鼓勵個案表達疾病及身體外觀帶來的衝擊感受，強化其適應及對生活習慣的改變，達到能正向面對身體改變及願意參與傷口照護、疼痛緩解及提升生活品質。透過此次經驗，建議未來護理師透過訓練能了解各式敷料及特性，發展傷口照護教學影片，提供病人及照顧者返家後也能使用，達到全程全社區醫療照護品質。

This article is a nursing experience of 48-year-old woman of breast cancer combined with mushroom-like wounds and bone metastasis. This case is a breast cancer (stage I) patient diagnosed in 2019, delayed treatment for some reason, when she come back to hospital, the breast tumor is ulcerated and bleeding, right lower limb bone metastasis also noted, with muscle strength deterioration resulted in changes in body appearance, difficulty moving, and had negative emotions, which triggered the author’s investigate. The nursing period is from March 20, 2022 to March 27, 2022, the author collected subjective and objective data through physical assessment, continuous care, interviews, and observation, finally established through the Roche Adaptation Model assessment: Pain, Tissue integrity are affected health problems such as damage to the body and mental image disorder. During the care period, pain control is carried out by diverting attention, limb support and drug treatment; assisting in choosing appropriate dressings to reduce wound odor and exudate during dressing changes, providing bright silk scarves to divert the focus of the wound, and encouraging active care and companionship. Encourage the cases express the impact of the disease and body appearance, strengthen their adaptation and changes in living habits, and achieve the goal of being able to face physical changes positively and be wiling to participate in wound care, pain relief and improve the quality of life.