本文是敘述一位糖尿病末期腎病變病患在接受血液透析治療初期一個月內因血管通路栓塞，需再次接受瘻管手術所引發生理、心理、社會的問題及其護理。筆者於93年2月12日至93年4月22日護理期間，利用Gordon十一項功能性健康型態評估個案，籍由觀察及訪談方式收集資料發現個案有：營養狀況改變、疼痛、健康尋求行為、身體心像紊亂、焦慮等主要護理問題。在護理過程中透過主動關懷、陪伴及傾聽，鼓勵個案表達其心中想法，與個案及家屬共同擬定計畫並提供所需之護理照護，協助個案處理生理不適並減輕心理疑慮，使個案能在護理人員及家屬支持下，面對疾病、恢復自信並回復往日生活。

This text describes the physiological, psychological and social problems as well as nursing of a patient with terminal diabetic nephropathy who had received hemodialysis treatment for only one month in the initial stage but must undergo an operation for fistula due to the vascular access embolism. The author based the case assessment based on Gordon 11-item Functional Health Pattern Assessment Method from Feb.12.to Apr. 22, 2004, collecting data by observation and interviews. The author found the patient suffered from some major nursing problems such as a changing nutritional situation, pain, eagerness to pursue health, body-image disturbance, anxiety,...etc. During the nursing process, the client was supported to confront the illness and restore the confidence and former life by the nursing team and their family through active concerning, companionship and listening. The client was also encouraged to express her mindsets. In the meantime, the medical personnel worked out projects together with the patients and their family to provide the imperative nursing care, and helped them to manage physiological malaise and eased their doubt about health.