本文描述一位糖尿病足截肢病患之照護經驗。筆者於98年9月23日至10月3日照護期間，運用Gordon十一項健康評估，並藉由直接護理、觀察會談、資料收集及追蹤訪談等方式，收集主、客觀資料加以分析整理，確立個案有「急性疼痛」、「皮膚完整性受損」、「自我照顧能力缺失」、「身體心像紊亂」護理問題。護理過程中，筆者針對個案護理問題提供個別性護理措施，給予心理支持及教導運用放鬆技巧等方式減輕疼痛不適；提供傷□照護及衛教，協助個案維持傷□清潔及預防傷□感染；藉由引發個案自我照顧的動機，使個案能配合復健治療增進日常生活功能；護理人員及家屬關心與支持，並採漸進式參與換藥過程，協助個案調適因截肢所導致身體心像改變，重建正向的自我概念，重新適應新的生活。希望藉此文獻探討及護理經驗的分享，作為臨床護理人員照顧類似病患之參考。
This study describes the nursing experience caring for a patient whose foot was amputated due to diabetes. During the nursing care which occurred from September 23, 2009 to October 3, 2009, methods such as Gordon's 11 functional health patterns assessment, direct nursing, observational interview, data collection, and follow-up interview were used to collect, analyze, and arrange both subjective and objective data. The patient's nursing problems were identified as "acute pain", "high risk for infection", "self-care deficit" and "body image disturbance." Nursing care focused on these problems. The patient was provided with emotional support and instructions on how to relax to alleviate pain and discomfort. The patient was also taught wound care, including how to maintain wound cleanliness and prevent wound infections and encouraged to cooperate with rehabilitation therapy aimed at increasing daily life functions and triggering the motivation to care for one's self. The concern and support of nursing staff and family, as well as the adoption of progressive participation in the changing of wound dressing promoted adjustment. The patient was also help to adjust to the changes in body image caused by amputation, reconstruct positive self-concept, and readjust to new life. It is hoped that our nursing experience can serve as a reference for clinical nurses caring for similar cases.
