- 期刊
全身性硬化症合併雷諾氏現象及趾潰瘍之照護經驗
The Caring Experience of a Systemic Sclerosis Patient Accompanying Raynaud's Phenomenon and Digital Ulcers
摘要
本文描述照護一位全身性硬化症個案出現雷諾氏現象合併趾潰瘍壞疽的護理經驗。此疾病為罕見自體免疫疾病，雷諾氏現象通常為首發症狀，易發生肢體末端缺血性潰瘍壞疽，若未妥善照護，可能需要立即性的醫療處理。筆者以Gordon 11 項健康功能進行身心社會及靈性之整體性評估，於2013 年10 月16 日至12 月9 日照護期間確立組織完整性受損、健康維護能力改變及無力感等健康問題，整合疾病照護相關知識及可用之醫療資源，給予個別性及可行性的護理計畫，協助控制感染、促進傷口癒合、加強健康維護能力及改善無力感。本護理過程除幫助個案正向面對健康改變之威脅，亦強化其對於疾病及相關合併症之自我照顧能力；出院後持續追蹤，以協助維持適當的健康維護行為，提升生活品質，此護理經驗可提供未來照護此類個案之參考。
並列摘要
This report describes the nursing experience for a systemic sclerosis subject with Raynaud's phenomenon combining digital ulcers. Systemic sclerosis is a rare auto-immune disease, and Raynaud's phenomenon is often presented as a first onset symptom. The peripheral limbs tend to demonstrate ischemic ulceration gangrene, and if not under appropriate treatment, it will become a medical emergency. Gordon health functional assessments were utilized to provide a comprehensive evaluation covering physical, mental and spiritual dimensions from October 16, 2013 to December 9, 2013. In the nursing period, health issues included impaired tissue integrity, change of ability to maintain health, and powerlessness. Individualized and feasible nursing care plans were implanted along with integrated health resources and disease related knowledge; in order to control infection, heal the wound, elevate health maintain ability and decrease powerlessness. The object was to not only help the subject to positively face the threats from disease, but also enhance self-care ability about the disease and its complications. Continuing follow-ups after discharge were aimed at helping build appropriate health promotion behaviors and increase quality of life. This nursing experience could provide a good reference for future cases.