橫紋肌溶解症併急性腎損傷之護理經驗－個案報告

本篇為照護一位25 歲男性，因突然的激烈運動後，導致腎組織灌流改變、疼痛、焦慮問題，而入加護病房之護理經驗。護理期間為2013 年7 月20 日至7 月26 日，筆者運用Gordon十一項健康功能型態評估架構，經由身體評估、觀察、溝通、會談及直接照護的方式收集資料，評估分析發現個案有(一) 腎組織灌流改變/CPK 過高及代謝性中毒有關；(二) 急性疼痛/肌肉急性損傷及乳酸堆積有關；(三) 焦慮/ 對橫紋肌溶解症知識、加護病房環境及儀器設備的不了解有關等健康問題。經由靜脈輸注0.9% 生理食鹽水200-300ml/hr 補充水分，以矯正體液酸鹼電解質的平衡；口服止痛劑Tinten 的給予，運用音樂療法、按摩、冰敷的使用，抬高肢體及舒適擺位；提供橫紋肌溶解症的知識、鼓勵說出心中想法並傾聽，教導深呼吸、漸進式肌肉放鬆技巧等護理措施介入後，使個案血中CPK 自10570U/L 降至778U/L，腎臟功能漸趨於正常，避免惡化形成急性腎衰竭；疼痛指數由6 分降至3 分；焦慮得以緩解由6 分降至2 分。運用專業護理指導及有計劃的護理措施，協助改善腎功能恢復正常、減輕疼痛、改善焦慮程度，增加對橫紋肌溶解症的預防保健觀念，更能顯示護理專業之獨特重要性。

關鍵字

橫紋肌溶解症；腎組織灌流改變；急性疼痛；焦慮

並列摘要

This paper describes nursing case study of a 25-year-old male patient in intensive care unit. The patient experienced a decrease of glomerular filtration rate, acute pain and anxiety after an intense exercise session. The nursing period was from 20th July to 26th July 2013. Gordon 11 functional health patterns framework was used through the collection of qualitative data (such as body examination), observations, communication with patient and direct nursing. Three observations of the patient were made: (1) changes in renal tissue perfusion/excess CPK value were related to metabolic acidosis; (2) a relationship between acute pain/injury of muscle and lactic acid accumulation, and (3) unfamiliar with the environment, lack of understanding of the equipment in intensive care unit and inadequate knowledge of rhabdomyolysis had resulted in patient's anxiety. 200- 300ml/hr of 0.9% saline was used for intravenous infusion to hydrate the patient and to moderate the electrolyte and acid-base balance of body fluid. Oral application of Tinten pain killer, music therapy, massage, icing and raise body to comfortable position helped the patient in pain reduction. Through provision of knowledge of rhabdomyolysis to the patient, encouragement to express his emotion, education on deep breathe and muscle relaxing techniques, his CPK value decreased from 10570U/L to 778U/L. Renal also started to function normally without worsening into acute kidney failure. Both pain value and anxiety value decreased from 6 point to 2 point.

並列關鍵字

Rhabdomyolysis ； Changes in renal tissue perfusion ； Acute

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橫紋肌溶解症併急性腎損傷之護理經驗－個案報告

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