- 期刊
照護一位罹患大皰性類天皰瘡病人之護理經驗
Nursing Experience of Caring for a Patient with Bullous Pemphigoid
摘要
本文為75歲男性罹患大皰性類天皰瘡，入院接受傷口照護治療之護理經驗。於2021/9/30至10/20運用Gordon十一項功能性健康型態評估工具，並藉由會談、身體評估、病歷查閱、直接照護及後續電話追蹤等方式收集資料，確立個案有皮膚完整性受損、急性疼痛及焦慮等健康問題。每天由兩位護理師協助大面積傷口換藥，若發現充盈水泡，會予消毒後刺破並抽出組織液，出院前全身傷口面積降至45%；此外，換藥過程中使用生理食鹽水沖洗傷口，降低敷料沾黏及組織危害，疼痛指數下降至3分。衛教避免生活壓力及勿亂服用成藥，個案因疾病預防認知提升進而改善焦慮。筆者使用四條治療巾做成背心固定敷料，建議未來可研發出軀體型網套或背心型敷料固定大面積傷口，進而促進傷口癒合。希望藉此經驗提供大面積傷口照護之參考。
並列摘要
This case report is based on caring for a 75-year-old man suffering from bullous pemphigoid, who was admitted to the hospital for wound care and treatment. The nursing period was from September 30 to October 20, 2021. The data was collected using the Gordon Eleven Functional Health Type Assessment Tool. Through interviews, physical assessment, review of medical records, direct care, and follow-up phone calls, it was established that the patient had health problems such as impaired skin integrity, acute pain, and anxiety. Two nurses used ointments to assist large-area wound dressing change every day. If a full blister was found, it was punctured after disinfection and the tissue fluid was drawn out to reduce infection caused by skin damage. The damaged wound area was reduced to 45%. In addition, normal saline was used to rinse the wound during the dressing change, reducing the pain of the dressing sticking and the harm of cell tissue. The wound pain index dropped to 3 points. Prevention of disease recurrence was achieved by avoiding life stress and not taking drugs indiscriminately. The anxiety of the patient was improved by enhancing the patient's awareness of disease prevention. The author used four therapeutic towels to make a vest for fixed wound dressing. It is suggested that in the future, body-type mesh sleeves or vest-type dressings should be used to fix large-area wounds and promote wound healing. It is hoped that this experience can provide a reference for large area wound care.