一位重度燒傷歷經多次植皮失敗個案之復健護理經驗

Nursing Experience in a Patient of Severe Burn with Several Unsuccessful Skin Grafts

10.30167/JOIT.201112.0016

黃僆倛(Lien-Chi Huang)；孫美華(Mei-Hua Sun)

燒傷 ； 植皮 ； 急性疼痛 ； 焦慮 ； 復健護理 ； Burns ； skin graft ； acute pain ； anxiety ； rehabilitation nursing

亞東學報

31期（2011 / 12 / 01）

157 - 168

繁體中文

本文是探討一位45歲女性個案因意外導致車輛起火造成全身二至三度47%燒傷入住燒傷中心治療的個案，筆者於2008年6月22日至8月13日照護期間與個案共同經歷急性期至復健期整個照護計劃，特別是在復健期的過程中，筆者運用Gordon十一項功能性健康型態評估，藉由觀察、會談及直接護理照顧等方式進行資料收集，確立個案有組織完整性受損、急性疼痛、焦慮及身體活動功能障礙等健康問題。筆者藉由衛教指導提供組織癒合相關照護知識促使傷口癒合，教導個案運用疼痛緩解技巧以減輕換藥時導致的急性傷口疼痛，透過主動關懷、傾聽及心理支持鼓勵個案表達手術經驗的焦慮與不安，並和個案進行互動式討論復健相關計劃，給予護理指導增進肢體活動功能，持續提供個案整體性之護理照護，以提升個案自我照護能力，重新面對家人及朋友並重返社會，期望透過此次護理經驗的分享，提供護理人員照護相關個案的參考。

The purpose of this article was to describe a 45 years old female who was admitted to the burn center as a result of an accident in which a vehicle in flame burn injury of 2-3 degree 47% TBSA. From June 22 to August 13, 2008, the author took part in the holistic care plan from the acute stage to the rehabilitation stage for the patient. In particular, on the rehabilitation stage, using Gordon's functional health assessment tool were adopted. By observation, conversation, and direct nursing care, data was collected to identified patient's health problems including impaired skin integrity, acute pain, anxiety, impaired physical mobility. During the nursing process, by health education, the author offered tissue healing care knowledge to help to make the wounds heal and instructed pain relieving skills to alleviate acute pains from dressings change. Through caring, listening, and psychological support, the patient was encouraged to speak out about her anxiety and misgivings about surgical failure experience, and a rehabilitation plan was discussed interactively. Moreover, nursing instruction was given to help to facilitate her limb function, and overall nursing care was provided incessantly to enhance self-care ability and returned back to family, friends and society. This experience provided nursing staff with a reference for caring similar patients in the future.

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