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的加護經驗

The Nursing Experience for a Stevens-Johnson Syndrome ICU Patient with Toxic Epidermal Necrolysis Complication

廖盈謹(Ying-Chin Liao) ； 蘇淑芬(Shu-Fen Su)

《弘光學報》 79期 (2017/03) Pp. 35-45

https://doi.org/10.6615/HAR.201703.79.03

摘要

本文是描述照護一位因服用非類固醇抗發炎藥物(NSAID)，產生藥物過敏，引發史帝芬強生症候群併發毒性表皮壞死溶解症患者的加護經驗，由於患者全身體表面積皮膚破損高達30%，造成生命危象，必須轉入加護病房，密切監測照護，但因嚴重皮膚受損造成巨大心理衝擊，筆者透過傾聽、會談並以Gordon十一項健康功能型態對患者進行仔細評估，護理期間為2015年3月23日至4月4日，發現個案有急性疼痛、皮膚完整性受損及身體心像改變等三個主要護理問題。筆者於照護過程中，隨時注意患者的生理及心理變化，給予個案適切的重症護理，以穩定生命徵象，並透過照相方式記錄傷口癒合情形，以協助個案了解傷口癒合進度，調適身體心像的改變，藉由主動傾聽關懷，及隨時釐清個案對病程的疑惑，與個案建立良好信任關係，並運用專業知識，提供直接的照護，避免感染，改善疼痛問題，使個案勇敢面對疾病帶來之身心衝擊，筆者期望此照護經驗，分享及提供護理同仁臨床照護之參考。

關鍵字

史帝芬強生症候群 ； 毒性表皮壞死溶解症 ； 身體心像改變 ； 加護經驗

並列摘要

This article is to describe the intensive nursing experience of caring for a 62-year old female patient suffering from Stevens-Johnson syndrome complicating with toxic epidermal necrolysis caused by NSAID allergy. Since the skin damage was over 30% of total body surface area among this patient, resulting in life threatening situation and enormous psychological impact. She was then sent to the intensive care unit for closely monitor and care. The data were collected through face to face interview, listening, and Gordon eleven Functional Health Patterns Assessment using as a tool for nursing evaluation. The nursing care period was from March 3 to April 4 in 2015. The three identified major healthcare problems of this patients were acute pain, impaired skin integrity, and body image change. Through the whole nursing process, the author paid attention to the physiological and psychological changes of this patient, provide appropriate intensive care to stabilize vital signs, and recorded wound healing situation through photos taking in order to help this patient to understand wound healing progress and adapt the change of her body image. The author also actively listened to the patient's concerns and feelings, clarified doubts of condition, and established a very good nurse-patient relationship with patient. In addition, the author used the professional knowledge to provide direct care in preventing infection and improving pain in helping the patient to face the mental and physical impact caused by this critical disease. We expect this care experience can be a reference for providing useful information for clinical nurses.

並列關鍵字

Stevens-Johnson syndrome ； toxic epidermal necrolysis ； body image change ； intensive care unit care

參考文獻

李叡筠、朱彥紅、江采宜、顧家恬(2015)‧銀離子敷料於傷口照護之文獻回顧‧澄清醫護管理雜誌，11(4)，43-50。

林安琪、謝碧霞、陳淑卿(2012)‧照顧一位燒炭自殺顏面燒傷患者之護理經驗‧長庚護理，23(4)，539-547。

黃立言、劉秉一、鄭幼文、張俊梁、諶立中、許文欣、柯富彰(2010)‧不只是皮膚疾病：以內科醫師觀點談毒性表皮溶解症‧內科學誌，21，12-25。

張瓈方、張乃文、王桂芸‧(2010)‧身體心像紊亂之概念分析‧長庚護理，21(1)，25-32。

詹淑雅、劉芹芳、金繼春(2011)‧身體心像紊亂之概念分析‧新臺北護理期刊，13(1)，63-72。