本文旨在探討一位因瓦斯氣爆造成燒燙傷之個案,在加護病房照護期間為2017年03月10日至2017年04月05日;以薄井坦子全人照護模式為指引,經由會談、傾聽、觀察等方式,依照身體、心理、社會及靈性層面進行護理評估及分析,確立於加護病房期間的健康問題有:急性疼痛、皮膚完整性受損、身體心像紊亂等三項護理問題;針對急性疼痛之健康問題,教導轉移注意力方法及與麻醉科醫師共同擬定止痛計畫,以減輕換藥造成的不適感,對於身體心像紊亂,引導其感受並提供適當之措施;而皮膚受損,除了與營養師討論麩醯氨酸(Glutamine)之使用外,每班使用全體圖像之人形圖記錄傷口敷料種類及傷口變化,並教導促進癒合方法及後續復健。希望藉由此篇護理經驗,提供給日後照護燒燙傷個案之護理人員做參考。
This paper aims to discuss a burnt patient from gas explosion, who had been in the intensive care unit during March 10, to April 5, 2017. Under the guide of Thin Well Tanzi full human care model, we applied the methods of conversing, listening, and observing to engage the nursing evaluation and analysis in terms of physical, psychological, social, and spiritual aspects. Consequently, we diagnosis the health problems during intensive care period includes acute pain, impaired skin integrity, and body, image disturbance. In terms of the nursing issues such as acute pain, we instruct the patient to shift the attention, consult anesthetist for pain relief plan in the course of applying medication. In regards to body image disturbance, we guided the patient's feeling and provided appropriate evaluation. In respect of impaired skin, besides discussing the usage of Glutamine with the nutritionist, we educate the patient the healing method and the follow-up rehabilitation. Hopefully, this nursing experiences can serve as a reference for nursing staff when looking after a burnt patient in the future.