本文描述一位女性運動員接受足踝韌帶重建手術後門診護理經驗。在2020年5月21日至7月16日,七次回診追蹤治療期間,運用Gordon十一項健康功能型態及簡易健康量表(Brief Symptom Rating Scale,BSRS-5)做為評估及透過實際照護、觀察、訪談及查閱病歷等方式資料收集,確立主要健康問題為:不確定感及焦慮、潛在危險性跌倒及潛在危險性感染。筆者於照護過程中,建立良好醫病關係及溝通技巧,引導個案說出焦慮,提供減輕的護理措施,讓不確定感及焦慮的情況得以改善;教導相關復健與輔具使用,預防跌倒的發生;運用照護技巧來降低潛在傷口感染問題。藉此照護經驗的分享,做為未來門診照護類似個案之參考。
This article describes the outpatient nursing experience of a female athlete who underwent foot and ankle ligament reconstruction surgery. During the seven follow-up visits from May 21 to July 16, 2020, Gordon's Function Health Patterns and Brief Symptom Rating Scale (BSRS-5) were used to assess and collect data through actual care, observations, interviews, and medical record reviews. It identified the main health problems as: uncertainty and anxiety, risk for falls and risk for infections. During the care process, the author established a good therapeutic interpersonal relationship and communication skill; guided the case to explain the reasons for anxiety and provided care measures to reduce uncertainty and anxiety; taught rehabilitation principles and the use of assistive devices to prevent falls; and used nursing skills to reduce potential wound infections. This sharing of care experience will serve as a reference for similar cases in future outpatient care.