照顧一位年輕乳癌病人合併腰椎轉移之護理經驗

Caring for a Young Breast Cancer Patient with lumbar spine metastasis Nursing Experience

10.6647/CN.202009_27(3).0013

曾婉婷(Wan-Ting Tseng)；陳姲諪(Yen-Ting Chen)；張嫚娜(Man -Na Chang)

急性疼痛 ； 身體功能活動障礙 ； 自我照顧能力缺失 ； 無望感 ； Acute pain ； physical activity dysfunction ； Deficiency of self-care ability ； Hopelessness

彰化護理

27卷3期（2020 / 09 / 01）

98 - 110

繁體中文

本文描述一位年輕乳癌女性因腰椎轉移造成下肢無力導致無法下床活動，因自我照顧能力受限及未知的治療結果而產生無望感。護理期間為2017.12/8～2017.12/20，藉由直接照護、觀察及會談等方式，運用Gordon11項功能性健康型態評估，確立護理問題為：急性疼痛、身體活動功能障礙、自我照顧能力缺失，無望感。會談中發現個案因腫瘤轉移與生活無法自理而感到沮喪，藉由主動關懷及陪伴，與個案建立信任之護病關係，希望提供個別性的護理措施及持續性的關懷，提升個案自我控制感及相關指導更顯重要，適切的疼痛評估，以藥物、轉移注意力及維持舒適臥位等方式改善手術後疼痛，共同討論復健計畫及鼓勵並積極陪伴參與復健運動，改善身體活動功能障礙及自我照顧能力缺失的問題，讓個案與家屬能在身心安適的狀態下有信心繼續未來的治療。

This article aims to describe a young woman with breast cancer with metastatic spinal tumor, and has leading immobility due to weakness of lower limbs. This process has leading hopelessness caused by self-care deficit and unknown ongoing treatment plan. Nursing care period was carried out since 8th of December till 20th of December in 2017, application of Gordon's eleven functional health pattern assessment through listening, observation and physical assessment. The nursing diagnosis and care plans included (1) acute pain, (2) physical activity dysfunction, (3) deficiency of self-care ability, (4) hopelessness. Through the conversation, nurses have observed patient felt frustrated due to unable to perform self-care in ADLs. Nurses has perform proactive care and companionship, to established a trustworthy nursing relationship, actively understand patients' inner feelings and needs, encourage participation in self-care programs, provide individual nursing measures and continuous care to improve the sense of self-control and relevant nursing guidance is crucial in this stage. Appropriate pain assessments, analgesia, divert attention away from anxiety and maintaining in a comfortable supine position to reduce postoperative pain. By cooperate with multi-disciplinary team to establish care plan with family members, to guide patient of gait balance training, rehabilitation exercises to improve physical activity dysfunction and promote self-care. Actively understand patients' inner feelings and needs, provide psychological supportive technique, which aims to reduce patient's psychological distress and anxiety throughout the illness. To assist patient and family in adapting to the changes of lifestyle and continue ongoing treatments in a state of physical and psychological well-being.

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