本篇報告係描述一位乳癌分化第三期,行右側乳房根除手術接受化療及放療後,再面臨淋巴水腫脹痛疑似肺部轉移,引起身心衝擊及調適經過之護理經驗。筆者於護理期間(2005年11/1~11/6)運用Gordon 11項功能性健康型態評估工具經由會談、觀察及身體評估的方法收集資料,歸納個案呈現主要的護理問題為:1.焦慮2.疼痛3. 身體活動功能障礙等。照護期間藉由傾聽、陪伴、同理心及醫療訊息的提供,建立良好護病關係及信任感,提供正確護理資訊及心理、社會支持,鼓勵說出心中感受,協助個案能正向面對病情,減輕身心困擾,提升自我照顧及調適能力,以維持最佳生活品質。藉由文中提出之臨床經驗,期望能作為護理人員日後照護類似病患之參考。
This report was to present the nursing experience of a patient who suffered from breast cancer stage Ⅲ post right mammectomy and chemo-radiotherapy, lymph edema with lung metastasis suspiciously, physical and mental impact, and coping process. Data collecting was used the Gordon’s Functional Health Assessment tool by interview, observation, and physical examination from 1-6, November, 2005. The major nursing problems were anxiety, pain and physical function disorder. During the care period, the author established good relationship and trust with patient by listening, company, empathy and medical message providing. Simultaneously, not only providing correct nursing information, mental and social support to encourage speaking about perception, but also assisting patient to face disease positively, reducing physical and mental problems, enhancing self-care and coping skill, to maintain the optimum quality of life. The nursing experience of this report can serve as a reference in the same field of nursing in the future.