敗血性休克使用升壓劑引發下肢壞疽病人之照護經驗

Experience of Caring for a Septic Shock Patient with Lower Extremity Gangrene Induced by Vasoconstriction from Usage of Vasopressors

10.29494/LN.201906_20(2).0004

葉書秀(Shu-Hsiu Yeh)；鄭婉如(Wan-Ju Cheng)；李佳欣(Chia-Hsin Li)；馬瑞菊(Jui-Chu Ma)

敗血性休克 ； 下肢壞疽 ； 身體心像紊亂 ； septic shock ； lower extremity gangrene ； body image disturbance

領導護理

20卷2期（2019 / 06 / 01）

42 - 54

繁體中文

罹患敗血症休克之病人，若出現無法藉由緊急輸液挽回之低血壓併發症時，升壓藥物的使用就是必要的選擇，而長時間血管收縮易造成上層皮膚壞死的風險，進一步演變成壞疽。本文係探討一位敗血性休克使用升壓劑導致下肢壞疽病人之護理經驗。照護期間為2015年5月15日至6月20日，筆者運用Gordon十一項健康功能型態評估，實際參與病人照護過程，透過觀察、身體評估、會談等方式收集主、客觀資料，確立健康問題為：一、現存性感染／與不明原因導致敗血性休克有關；二、組織完整性受損／與升壓劑使用後下肢壞疽之合併症有關；三、身體心像紊亂／與雙腳壞疽、面臨截肢有關。在護理過程中，避免下肢靜脈給藥、早期停止升壓藥物且密切監測末梢循環，避免續發性感染；與其建立良好護病關係，促進對事實的察覺，緩解及修正身體心像紊亂。病人傷口雖面臨截肢，但在醫療團隊共同努力下，無產生其他合併症，且能正向、樂觀地面對其傷口。臨床使用升壓藥物病人，常有末梢缺血發紺，甚至壞疽情形，故建議製作升壓藥物衛教單張以減輕病人家屬之疑慮。亦建議醫療團隊需明訂用藥標準流程及藥物使用查檢表，以維護病人用藥之安全。期望藉由這次護理過程，提供日後照護此類病人之參考。

For patients who experience septic shock and developing hypotension complications that cannot be managed through emergency fluid resuscitation, vasopressors become an essential option. However, inducing vasoconstriction over an extensive period leads to high risk of dermal necrosis, hence advances into gangrene. This study examines the nursing experience of a patient who ultimately developed gangrene in the lower extremities from using vasopressors during septic shock. The nursing period spanned from May 15 to June 20 of 2015. The author participated in direct caring for the patient, applied Gordon's 11 Functional Health Patterns Assessment to collect both subjective and objective data through methods such as observations, physical examinations, and conversations. Hence confirmed the patient's problems include existing infection, impaired tissue integrity, and body image disturbance. In order to avoid administering drugs through the veins in the lower extremities, vasopressor infusion was terminated at an early stage and peripheral circulation was closely monitored to avoid secondary infection. Additionally, by building rapport with the patient, the patient gradually recognized and accepted the body image change, ultimately relieved body image disturbance. Although the patient faced amputation, through the joint effort of the medical teams, no other complications occurred and the patient accepted the wound with a positive and optimistic attitude. Peripheral cyanosis often occurs during clinical practices when vasopressors are administered to patients, which may develop into gangrene. Therefore, this study recommends education pamphlets on vasopressors to be designed for relieving patient families' concerns. Furthermore, it is necessary for medical teams to formulate a medication administration protocol and a medication dosage checklist to ensure patient's medication safety. This nursing experience hopefully serves as a reference for providing care to similar patients in the future.

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