91 一位惡性蕈狀傷口合併腸皮瘻管個案之護理經驗 莊玟玲謝岫庭 * 本文呈現照護一位大腸癌末期因癌細胞擴散, 於右腰形成惡性蕈狀傷口, 且合併腸皮瘻管之個案 護理經驗 護理期間為 2006 年 4 月 22 日至 6 月 25 日, 經由 Gordon 的十一項評估進行資料收集, 確認個案健康問題為慢性疼痛 睡眠型態紊亂 組織完整性受損及身體心像紊亂 由於本文著重 腸皮瘻管的照護, 故僅分享組織完整性受損之護 理過程, 筆者與醫療團隊經由腦力激盪與創新, 應用各種方式, 改善糞便持續滲漏至傷口與臭味 的問題, 以促進個案的舒適與改善生活品質, 更 協助患者完成心願, 安詳走完人生最後的旅程, 本照護經驗可提供臨床照護類似個案時的參考 惡性蕈狀傷口 腸皮瘻管 傷口護理 56 McMurray, 2003 Naylor, 2002 Haffejee, 2004 Chaplin & Curie, 2004 2007 2004 2000 2004 0.9 Bauer, Gerlach, & Doughty, 2000 250mg 500mg Flagyl Bauer et al., 2000 Naylor, 2002 Maria, Kathryn, & Georgene, 200010 15 1:1000 Bosmin 2007 Bauer et al., 2000 2004 2007 Haffejee, 2004 2 15% Berry & Fischer, 1996 * 97 4 9 97 10 13 901 06 2812811 55899
92 Enterocutaneous Fistula Haffejee, 2004 1998 Haffejee, 2004 500ml/ 50ml/ 1998 De Weerd, Kjaeve, Aghajani, & Elvenes, 2007 72 30 91 12 92 1 93 2 93 772 52 2594 7 10 95 4 95.4.22 95.6.2595.6.25 Gordon ㈠ ㈡ 157 54 52.2 10 15 4.4 6 ㈢ ㈣ ㈤ ㈥ 13 5 喔! 2 ㈦ 傷口會很大嗎? 傷口會臭, 換藥時要戴口罩 傷口常有糞便滲出來, 把我的衣服都
93 滲濕 ㈧ ㈨ 30 ㈩ 宗教信仰讓我心情平靜, 心靈有寄託 4/22 1. 糞便一直從傷口滲出來, 怎麼辦? 2. 一天要換藥好多次, 身體像泡在大便, 濕濕黏黏的, 好臭 3. 半夜都會擔心糞便漏出來, 晚上還要起來換藥換衣服 4/22 1. 10 15 4.4 2. 3. 4. 4~6 5. 6. 5 7. 5/5 1. 1. 5/5 2. 5/8 3. 5/10 4. 5/12 4 6 3 5. 5/14 6. 5/16 5 7. 5/20 1. 2. 3. 5/4 4. 5/8 5. 5/8 6. 5/9 7. 5/11 7-1 7-2 50ml 7-3 Posumin 1:1000 7-4 7-5 250mg Flagyl 7-6 1 3Gentamycin 7-7 8.0 7-8 op-side 8. 81 1 9. 10. 250mg MgO 2 11. 1. 5/5 6 2. 5/5 3. 5/8 4. 5/8 1 5. 5/8 6. 5/9 7. 5/10 8. 5/11 9. 5/12 3 10. 5/14 1000ml 11. 5/16 4 12. 5/17 13. 5/20
94 Enterocutaneous Fistula Maria et al., 2000 Grogan & Kramer, 2002 1000ml Bird 2000 Burns & Stephens, 2003 2007 274 290 2004 9 3286 291 1998 9 47 51 2000Orem 47 4101 108 Bauer, C., Gerlach, M., & Doughty, D. (2000). Care of metastatic skin lesions. Journal of Wound, Ostomy & Continence Nursing, 27(4), 247 251. Berry, S. M., & Fischer, J. E. (1996). Classification and pathophysiology of enterocutaneous fistulas. The Surgical Clinics of North America, 76(5), 1009 1018. Bird, C. (2000). Supporting patients with fungating breast wound. Professional Nurse, 15(10), 649 652. Burns, J., & Stephens, M. (2003). Palliative wound manage-
95 ment: The use of a glycerine hydrogel. British Journal of Nursing, 12(6), 14 18. Chaplin, J., & Curie, M. (2004). Wound management in palliative care. Nursing Standard, 19(1), 39 42. De Weerd, L., Kjaeve, J., Aghajani, E., & Elvenes, O. P. (2007). The sandwich design: A new method to close a high-output enterocutaneous fistula and an associated abdominal wall defect. Annals of Plastic Surgery, 58(5), 580 583. Grogan, T. A., & Kramer, D. J. (2002). The rectal trumpet: Use of a nasopharyngeal airway to contain fecal incontinence in critically ill patients. Journal of Wound, Ostomy and Continence Nursing, 29(4), 193 201. Haffejee, A. (2004). Surgical management of high output enterocutaneous fistulae: A 24-year experience. Current Opinion in Clinical Nutrition and Metabolic Care, 7(3), 309 316. Maria, D., Kathryn, D., & Georgene, H. (2000). Options for managing an open wound with draining enterocutaneous fistula. Journal of Wound, Ostomy & Continence Nursing, 27(2), 118 123. McMurray, V. (2003). Managing patients with fungating malignant wounds. Nursing Times, 7(3), 55 57. Naylor, W. (2002). Malignant wounds: Aetiology and principles of management. Nursing Standard, 16(52), 45 56. Nurse s Experience Caring for a Patient With Malignant Fungating Wound With Enterocutaneous Fistula Wen-Ling Chuang Shu-Ting Hsieh * Abstract: This report describes a nurse s experience treating a metastatic skin lesion with draining enterocutaneous fistula located in the right posterolateral abdomominal wall. The period of nursing care ran from April 22th through June 25th, 2006. In studying the nursing process, Gordon s assessment tools were used to gather subjective and objective data to establish critical care issues, which included chronic pain, sleep pattern disturbance, impaired tissue integrity, and disturbed body image. The focus of care was to manage the pain and irritation caused by the fistula of enterocutaneous. Targeting the issue of impaired tissue integrity, we developed and applied various methods to decrease the wound macerated from fecal, control odor, maintain patient comfort and improve patient quality of life. We helped the patient achieve her wish to end her life in peace. This nursing experience may provide a reference in caring for such cases in the clinic. Key Words: malignant fungating wound, enterocutaneous fistula, wound care. RN, MSN, Wound Care Specialist, Department of Nursing, Chi Mei Medical Center; *RN, BSN, Department of Nursing. Received: April 9, 2008 Revised: June 20, 2008 Accepted: October 13, 2008 Address correspondence to: Wen-Ling Chuang, No. 901, Chunghwa Rd., Yongkang City, Tainan County 71004, Taiwan, ROC. Tel: +886 (6) 281-2811 ext. 55899; E-mail: 300030@mail.chimei.org.tw