一位天疱瘡年輕女性面臨全身水泡及傷口之護理經驗

Nursing Experience of Young Female with Pemphigus Vulgaris encountering General Bullae

劉芷音(Chih-Yin Liu) ； 許玉芬(Yu-Fen Hsu)

《彰化護理》 25卷1期 (2018/03) Pp. 74-86

https://doi.org/10.6647/CN.201803_25(1).0011

摘要

本篇乃探討一位天疱瘡年輕女性面臨全身水泡及傷口之護理經驗。護理期間自2014年4月26日起至5月14日止，筆者運用Gordon十一項健康功能型態為評估工具，住院期間透過陪伴、溝通及傾聽等技巧，建立良好的治療性關係並進行資料收集，分析後確立個案有皮膚完整性受損、急性疼痛、身體心像紊亂等護理問題，針對上述筆者提供具個別性且整體的護理計畫及措施。於照護過程中，協助個案建立完整的傷口照護計畫，加強預防傷口感染及改善疼痛問題，給予促進傷口癒合之營養衛教，及教導對疼痛注意力之轉移技巧：另外運用護理專業知識幫助個案心理調適，顯著改善個案各項重理問題，教導個案自我照顧並引導家屬陪伴及參與照顧過程，使個案勇敢面對身體外觀的改變，並提昇自我價值及居家自我照護能力，且於出院後持續以電話訪談關心追蹤。筆者期望藉由此護理經驗之分享，提供日後護理同仁臨床照護之參考。

關鍵字

天疱瘡 ； 年輕女性

並列摘要

The article is about the experience of nursing a young female with pemphigus vulgaris encountering general bullae. The author assessed the patient by means of Gordon 11 functional health patterns questions during 26th april 2014 and 14th May 2014. By companionship, communication and listening to the patient, the author established fine therapeutic relationship and collected data to confirm that the patient had defect in skin integrity, acute tenderness and disturbance of physical and mental condition. According to the problems, complete nursing program was provided. The patient was assisted with establishing a detailed wound caring plan, preventing wound infection and pain control. The patient was also guided with regard to improving wound healing, nutrition education and attention diversion. Professional nursing experience was provided (or psychological adjustment and improvement of each nursing problems. The patient was also taught to care herself and her families were encouraged to involve in the process, which made her brave to confront the alternation of body figure, to increase self-worth and ability of home care. After the discharge, she was followed up with telephone interview. The author wished to provided the experience by sharing this nursing experience.

並列關鍵字

pemphigus vulgaris ； young female

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