照護一位施打抗蛇毒血清導致過敏性休克個案之急診護理經驗

Emergency Experience in Caring for a Case of Anti-venom Serum-induced Anaphylactic Shock

10.6692/KJN.202004_37(1).0005

潘美玉(Mei-Yu Pan)；蕭文惠(Wen-Hui Hsiao)；郭芳里(Fang-Li Kuo)；李佩玲(Pei-Ling Lee)

蛇咬傷 ； 抗蛇毒血清 ； 過敏性休克 ； 腔室症候群 ； 急診護理 ； snake bite ； anti-venom serum ； anaphylactic shock ； compartment syndrome ； emergency nursing

高雄護理雜誌

37卷1期（2020 / 04 / 01）

52 - 63

繁體中文

本文主要描述一位中年男性於果園工作時遭毒蛇咬傷，就醫後施打抗蛇毒血清而發生過敏性休克，爾後併發腔室症候群而緊急施行外科減壓手術之急診個案照護經驗。護理期間為2017/10/29 20：39-22：00，運用Gordon十一項健康功能型態分析歸納個案有「組織灌流改變：與過敏性休克造成全身灌流不足有關」及「急性疼痛／與毒蛇咬傷的傷口及其皮下組織腫脹有關」、「焦慮／與病情發展變化、健康狀態受到威脅及對事件缺乏控制感有關」之健康問題。筆者採積極性的照護模式，觀察其過敏性休克及腔室症候群進展，以預防危險性傷害之發生；並運用身體評估技巧評估個案之疼痛，適時以導入腹式深呼吸法、按摩、祈禱等轉移注意力方式以減緩其不適。接續協助澄清個案對疾病過程、治療之疑慮以減低焦慮感。希冀分享此照護經驗讓護理同仁更加了解如何協助此類病患度過生理及心理危機，進而提升急診照護品質。

This article mainly describes our emergency caring experience for a middle-aged male suffering from anti-venom serum-induced anaphylactic shock with complicating compartment syndrome undergoing emergent decompression surgery. During the nursing period from 2017/10/29 20:39 to 22:00, we evaluated the patient with Gordon's eleven health functions, and found some health problems including ＂change in tissue perfusion＂, ＂acute pain＂ and ＂anxiety＂. In order to prevent further progression, we adopted an integrated care model to monitor the course of anaphylactic shock and compartment syndrome. We also used physical assessment techniques and timely nursing intervention to relieve his pain and discomfort. Finally, we helped the patient to understand more about the disease and current treatment to reduce his anxiety. We hope that by sharing this care experience, our nursing colleagues can better know how to help this kind of patient overcome physical or psychological crises and also improve the quality of emergency care and patient satisfaction.