照顧一位史蒂芬強生症候群併毒性表皮壞死溶解症病人之護理經驗

The Nursing Care Experience of Caring for a Patient with Steven-Johnson Syndrome combined with Toxic Epidermal Necrolysis

郭恬妘(Tien-Yun Kuo)；陳怡燐(Yi-Lin Chen)；廖婕彣(Chieh-Wen Liao)

史蒂芬強生症候群 ； 毒性表皮壞死溶解症 ； 焦慮 ； Steven-Johnson Syndrome ； Toxic Epidermal Necrolysis ； Anxiety

嘉基護理

22卷2期（2022 / 12 / 01）

26 - 35

繁體中文

本文敘述一位因藥物不良反應引起毒性表皮壞死溶解症，造成全身70%體表面積皮膚壞死剝離之照護經驗；護理期間2021年3月1日～3月18日依據Gordon十一項健康功能型態評估工具進行護理評估，確認個案有急性疼痛、皮膚完整性受損、焦慮等問題；疼痛方面，教導深呼吸放鬆技巧、音樂療法、芳香療法、調整藥物使用等，以減輕疼痛感；皮膚完整性受損方面，傷口以銀離子敷料換藥、塗抺嬰兒油或保濕乳液保護皮膚、衛教食用足夠熱量與蛋白質補充，促進皮膚傷口癒合；焦慮方面，鼓勵個案表達內心感受、接納想法、給予情緒宣洩空間與心理諮商、運用衣物穿著遮蓋受損處、正念冥想，減輕個案焦慮情形，使個案正向面對疾病；建議單位培育傷口照護種子人員，定期規劃課程及會議討論個案，將單位困難傷口的個案提出討論，並回饋單位，提升傷口照護滿意度，縮減個案住院天數。

This paper described the nursing care experience of toxic epidermal necrolysis caused by adverse reactions to drugs, resulting in skin necrosis and stripping and mucosal ulcer covering 70% of the surface area. During the period of nursing care from March 1 to March 18, 2021. Nursing assessment based on Gordon's eleven health functional assessment tools, the case was confirmed to experience acute pain, impaired skin integrity, anxiety, and other problems. In terms of pain, deep breathing to relax, music therapy, aromatherapy, adjusting medication, etc., were imparted to alleviate the sense of pain. In terms of impaired skin integrity, the wound was dressed with silver ion dressing. Baby oil or moisturizing lotion was applied to protect the skin. A clinic consultation was held with a nutritionist to adjust the formula and provide adequate calories and protein supplements to promote wound healing. In terms of anxiety, the case was encouraged to express her inner feelings and accept others' opinions. A space for emotional catharsis and psychological counseling was provided. Clothes were used to cover the injured site, so as to boost the patient's self-esteem. Mindfulness yoga and meditation were applied to reduce the anxiety, enabling him to positively face the disease, It is recommended that the unit cultivate wound care seed personnel, regularly plan courses and meetings to discuss cases, discuss the cases of difficult wounds in the unit, and give back to the unit to improve wound care satisfaction and reduce the length of hospitalization for cases.

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