運用目標導向液體復甦於一位大面積燒傷病人之護理經驗

Nursing Experience of Appling Goal-Directed Fluid Resuscitation for a Patient with Major Burns

10.29494/LN.202103_22(1).0008

邵佳慧(Chia-Hui Shao)；楊嘉禎(Chia-Chen Yang)

重度燒傷 ； 輸液復甦 ； 目標導向治療 ； major burn ； fluid resuscitation ； goal-directed therapy

領導護理

22卷1期（2021 / 03 / 01）

99 - 113

繁體中文

本文為一位因工作意外導致2－3度25％體表面積燒燙傷病人之護理經驗，2017年5月25日至6月20日，藉由Gordon 11項健康功能型態評估，確立有「體液容積缺失」、「急性疼痛」、「組織完整性受損」、「身體心像紊亂」等問題。輸液復甦治療對重度燒傷病人為重要且持續更新的議題，而傷口更帶來疼痛、感染風險及造成外觀改變，護理過程中運用目標導向輸液復甦、監測各項生理數值，給予適當輸液量達到足夠組織灌流以避免產生併發症。提供有效控制疼痛控制策略，降低對傷口換藥之恐懼且主動參與換藥。教導傷口照護、實行感染控制避免傷口感染。透過持續關懷、陪伴、支持及傾聽等，使其克服身體心像紊亂，順利返家。期待透過此照護經驗，並作為日後臨床照顧之參考。

This article describes a male who suffered from 2-3 degree burn on 25% body surface area in a work accident. From May 25th to June 20th, 2017, during his hospitalization, the author identified the health problems using Gordon's functional health assessment tool. The health problems include fluid volume deficit, acute pain, impaired skin integrity, and body image disturbance. Fluid resuscitation is a renewing topic and critical to patients suffered from the major burn. Meanwhile, there are issues caused by burn wounds like pain and infection control, body image disturbance due to appearance change. The author monitored the physiological condition and used a goal-directed fluid resuscitation protocol, and gave proper fluid volume to avoid complications while providing enough tissue perfusion. By strategy of pain control, alleviated the patient's fear and then made him actively participate in the process of change dressing. Moreover, the author offered wound care education and home-care cautions to the patient and carried out infection control procedures to prevent potential infection. With caring, accompany, support and listening, giving instructions and encouragement to help the patient to face the change in body image and finally be discharged smoothly. By this article, the author hopes to share the care experience for better knowledge and care quality in the future.

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