本文描述一位57歲男性患有韋格納氏肉芽腫疾病,此次因疾病復發侵犯中樞神經系統,造成右側梗塞性小腦中風合併右耳聽覺喪失之護理經驗。筆者於2016年12月10日至24日照護期間藉由直接照護、觀察、會談、病歷查閱、身體評估方式收集資料,運用Gordon十一項健康功能進行評估,確立病人有不確定感、潛在性跌倒、言詞溝通障礙/與中度聽力損傷有關等健康問題。照護期間,病人因疾病導致身體平衡功能不佳、右耳聽覺喪失及因疾病復發生命備感威脅,無法預期治療效果及預後,對未來產生不確定感,經由鼓勵病人主動參與自我照顧計畫,提供疾病相關訊息,增加疾病認知及提升自我照護技巧,以減少病人對疾病預後之不確定感,同時運用跨領域醫護團隊合作模式,擬訂個別性及適切性護理措施,協助病人面臨身體平衡功能不佳及聽力損傷所造成的心理衝擊,冀透過此病人經驗的分享,做為相關疾病照護之參考。
This article describes a 57-year-old man suffering from Wegener's granulomatosis due to invasion of the central nervous system, resulting in the right cerebellar infarction, the right ear hearing loss and imbalance of physical activity. During the nursing period from December 10th to 24th, 2016. Data collection was done through observations, interview and physical examinations as well as the Gordon's 11 Functional Health Pattern Assessment to identify nursing care problems, such as uncertainty, potential risk of falls and impaired verbal communication. During hospitalization, to reduce the uncertainty of prognosis, we encouraged cases to actively participate in self-care programs and provide disease-related information. Using cross-disciplinary teamwork and designing appropriate and individualized nursing measures help the cases to face the imbalance of physical activity and the psychological impact caused by hearing loss. It is hoped through sharing this case experience as a reference for future care.