照顧一位電灼傷個案之加護經驗

Intensive Nursing Experience of Care for an Electrical Burn Patient

鐘珮真(Pei-Zhen Zhong)；趙紀硯(Chi-Yan Chao)

電灼傷 ； 身體心像紊亂 ； 加護經驗 ； disturbed body image ； electrical burn ； Intensive nursing experience

志為護理-慈濟護理雜誌

21卷3期（2022 / 06 / 01）

123 - 133

繁體中文

本文探討一位25歲年輕男性因工作不慎誤觸高壓電，導致全身深度達2－3度電灼傷，佔總體表面積45%個案之加護經驗。2020年2月19日至3月26號照護期間，運用羅氏適應模式為評估架構，藉由觀察、會談、身體評估及病歷翻閱等技巧進行資料收集，確立個案有組織完整性受損、急性疼痛與身體心像紊亂等健康問題。在護理措施方面，除了落實標準防護措施及遵守無菌技術傷口換藥以外，提供合適營養攝取及新生皮膚照護技巧教導，換藥過程中介入非藥物處置，緩解傷口疼痛，並運用簡易燒傷特定健康量表評估個案生心理及社會健康狀況，引導正向面對未來及重返社會。期望藉此照護經驗的分享，能提供臨床護理人員照護燒燙傷相關個案的參考。

This article describes the intensive care experience provided for a 25-year-old male patient suffering from shallow second degree to third degree burns on 45% of body surface area due to accidentally touching high voltage electrical cable at work. During February 19, 2020 to March 26, 2020, we applied Roy's adaptation model to assess and improve the patient's health with the methods of observation, conversation, physical assessment and history review. The result indicated that the patient's nursing problems included impaired tissue integrity, acute pain, and disturbed body image. In regard to nursing process, we used standard precautions, complied with aseptic dressing technique and provided guidance on adequate nutrition therapy and newly developed skin care education. During dressing change, we applied non-drug treatment to reduce the pain. The Burn Specific Health Scale-Brief (BSHS-B) was also employed to assess the patient's physical, psychological and social health condition. We provided mental health support to adequately release emotion, and guide the patient in positive thinking and future planning. We anticipated the patient's successful return to society and social functioning. We share the care experience with this patient as a reference for clinical nursing practitioners dealing with care of burn cases.

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