一位橫紋肌溶解症病人之急診護理經驗

An Emergency Nursing Experience of a Patient with Rhabdomyolysis

李慧瑩(Hui-Ying Li) ； 張淑華(Shu- Hua Chang) ； 賴美玉(Mei-Yu Lai)

《高雄護理雜誌》 34卷3期 (2017/12) Pp. 116-127

https://doi.org/10.6692/KJN.201712_34(3).0011

摘要

本文描述一位在高溫的環境下工作因脫水併發熱衰竭，進而產生橫紋肌溶解症病人之急診護理經驗。護理期間為2014 年8 月1 日16：12 至8 月1 日23：12 止，以觀察、會談、身體評估及病歷查閱等方式，運用歐倫自我照顧需求理論進行評估，發現病人主要護理問題依序有：急性疼痛、體液容積不足及焦慮。針對急性疼痛問題，提供個別護理措施，給予冰敷患肢。每小時監測生命徵象，依醫囑給予充分靜脈注射生理食鹽水及密切監測尿液變化，促進恢復體液及電解質之平衡。照顧期間與病人建立信任的護病關係，引導病人說出心中感受及想法，依據病人認知程度，提供口頭及書面護理資料協助理解橫紋肌溶解症及相關事項，並鼓勵家屬共同參與照護讓病人感受家屬之關懷，降低雙方內心焦慮。期盼此文能提供第一線急診護理人員照護類似病人之參考，提升急診整體性護理之照護品質。

關鍵字

橫紋肌溶解症 ； 急診 ； 護理

並列摘要

This article describes an emergency nursing experience of a patient with rhabdomyolysis caused by heat exhaustion and severe dehydration after a prolonged working period in a hot environment on August 1st, 2014 between 16:12 to 23:12 p.m. Once the patient was rushed to hospital, three major medical nursing problems were discovered; namely, acute pain, body fluid depletion and anxiety. Orem`s Self Care Theory was applied through interview for physical assessment and medical history recording. Individualized nursing intervention was provided to make sure the patient was maintained in a comfortable position to alleviate pain. The patient's vital signs were monitored hourly, fluid was replenished intravenously and urine output was watched closely, while restoration of body fluid and maintenance of electrolyte balance were also employed by physician's orders. During the period of nursing care, a relationship of trust was established between the caring nurse and the patient as well as his family. He was encouraged to express his concerns. Verbal and written information about understanding rhabdomyolysis was provided according to his cognitive level. His family was invited to participate in the patient's care to ease his anxiety. In an emergency care unit, nurses are expected to be able to build a trusting relationship with any patient in a very short period of time, when providing definitive nursing care. This article provides a reference for emergency nurses when dealing with similar diseases and situation.

並列關鍵字

Rhabdomyolysis ； Emergency ； Nursing

參考文獻

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