照護一位罹患史蒂芬強生症候群併發毒性表皮壞死溶解症患者之急診護理經驗

Urgent Nursing Experience of a Steven-Johnson syndrome Patient Complicated with Toxic Epidermal Necrolysis

張惠茹(Hui-Ju Chang) ； 郭嘉琪(Chia-Chi Kuo) ； 白佳玉(Chia-Yu Pai) ； 吳貞鋆(Chen-Yun Wu)

《領導護理》 18卷4期 (2017/12) Pp. 34-47

https://doi.org/10.29494/LN.201712_18(4).0004

摘要

本文旨在分享一位因藥物不良反應致毒性表皮壞死分解症引發全身75％體表面積皮膚糜爛性水皰、表皮壞死剝離病人之急診護理經驗。照護期間爲2015年10月22日08:10到10月23日12:15，筆者以Gordon十一項健康功能型態爲評估架構，運用身體評估，會談，查閱病歷等技巧收集資料，確認個案有急性疼痛、皮膚完整性受損、身體心像改變之健康問題。困難傷口照顧與難以接受身體心像改變，使病人一度拒絶治療，急診醫護團隊首先藉由疼痛處置與傷口護理，緩解生理不適，再藉由陪伴、關懷、抒發負向心理感受、引導正向思考、鼓勵參與傷口照護活動，協助克服身體心像改變的困擾，並在尋求傷口護理師照會協助下，解決病人的困難傷口照護問題，後續於次日轉燒燙傷加護病房接受進一步治療。

關鍵字

毒性表皮壞死分解症 ； 急性疼痛 ； 皮膚完整性受損 ； 身體心像改變

並列摘要

This paper describes the urgent nursing experience of treating a patient suffering from adverse drug reactions with toxic epidermal necrolysis, which induced erosive blisters on 75% of the patient's body surface, and necrotic epidermal detachment. During the nursing period from 8:10 a.m. on October 22 to 12:15 p.m. on October 23, 2015, Gordon's 11 functional health patterns were utilized as the assessment framework, and data was collected through physical assessments, conversations, and chart reviews. The health problems included acute pain, impaired skin integrity, and body image change. As the patient's wounds were difficult to treat, in addition to their inability to accept their changes in body image, the patient initially refused treatment. To resolve this problem, our emergency medical team first alleviated the patient's pain and treated their wounds to ameliorate physical discomfort. Then, through the application of skills such as accompaniment, caring, and expression of negative psychological feelings, the patient was guided towards positive thinking, and encouraged to participate in wound-caring activities and overcome the problems related to a disturbed body image. The problem of difficult wound care was also resolved with the help of a wound specialist. The patient was transferred to the burns intensive care unit the next day to receive further treatment.

並列關鍵字

toxic epidermal necrolysis ； acute pain ； impaired skin integrity ； body image change

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