- 期刊
照顧單臂異體移植個案之護理經驗
Nursing Experience of a Single-Arm Allogeneic Transplant
摘要
本文敘述一位單臂異體移植個案之護理經驗，於2018年3月13日至21日藉由傾聽、觀察及會談，運用Gordon十一項功能性健康型態評估為指引，收集主、客觀資料，發現個案有疼痛、高危險性感染、身體活動功能障礙及焦慮等問題。照護過程中建立良好關係，轉移注意力緩解疼痛、執行無菌傷口照護並評估異體手臂變化、給予保護性隔離與集中照護、提供移植資訊、設計輔助工具增加肢體活動，鼓勵表達想法及心理支持，傾聽陪伴緩解焦慮，協助調適身體變化，以正向態度面對治療；移植觀察重點為皮膚有無異常紅疹、監測免疫數據，避免產生嚴重排斥，即時通報及每日團隊會議給予適切醫療處置，可增加移植成功率，期望藉此經驗提供護理人員參考。
並列摘要
This article describes the nursing experience of a single-arm allograft case. The nursing period lasted from March 13 to 21, 2018. With Gordon's functional health patterns as the framework for assessment, the author collected data by observing and interviewing the patient. Nursing problems including acute pain, risk for infection, impaired physical mobility, and anxiety were assessed. The results showed that all of the following can increase the success rate of transplantation: Establish a good relationship during the care process, divert attention to relieve pain, perform sterile wound care and assess changes in allogeneic arms, provide protective isolation and centralized care, provide transplant information, design aids to increase physical activity, encourage the expression of ideas and psychological support, listen, relieve anxiety, assist with adapting to physical changes, and face treatment with a positive attitude. Transplant observations focused on skin rash, monitoring immune data, avoiding serious rejection, immediate notifications, and daily team meetings to determine appropriate medical treatment. It is hoped by that sharing this experience, it can be used as a reference for providing clinical nursing care.