照護一位被雨傘節毒蛇咬傷導致急性呼吸衰竭病人之加護經驗

Intensive Nursing Experience of Care for a Patient with Respiratory Failure by bitten with Bungarus multicinctus

王姿盈(Zi-Ying Wang)；林筱青(Hsiao-Ching Lin)

雨傘節咬傷 ； 急性呼吸衰竭 ； 焦慮 ； many-banded krait ； acute respiratory failure ； anxiety

嘉基護理

24卷1期（2024 / 06 / 01）

56 - 67

繁體中文;英文

本文為一名61歲男性病人，因雨傘節毒蛇咬傷併發急性呼吸衰竭，經醫療團隊照護，提供個別性及專業護理，順利轉出加護病房之護理經驗。照護期間2022年08月13日～08月26日，運用Gordon十一項健康功能型態評估，確認健康問題：呼吸道清除功能失效／與雨傘節蛇毒導致呼吸肌肉無力有關；現存危險性過敏反應／與施打蛇毒血清造成遲發性過敏有關；焦慮／與疾病威脅、是否能順利脫離呼吸器及預後不確定感有關。有別於急診護理師著重於初步毒蛇咬傷處理，建議加護單位可舉辦不同毒蛇咬傷併發症及後遺症相關在職教育，增加加護病房護理師的照護能力及知識。希望藉由此照護過程與經驗，提升護理角色功能的重要性。

This article is about the nursing experience of a 61-year-old male provide individualized and professional nursing-care patient who was bitten by many-banded krait (Bungarus multicinctus) and suffered from acute respiratory failure. He was successfully transferred out of the intensive care unit (ICU) under the care of the medical team. During the care period from August 13 to August 26, 2022, Gordon's 11-item health function assessment was used to confirm health problems: failure of respiratory clearance function/related to respiratory muscle weakness caused by snake venom; dangerous allergic reactions/related to the delayed allergy caused by the venom antiserum; anxiety/related to the threat of the disease, whether he can be successfully weaned from the respirator, and the uncertainty of the prognosis. Different from emergency-room nurses who focus on initial snake bite treatment, it is recommended that intensive care units can organize in-service education about the complications and sequelae of different snake bites to increase the nursing capabilities and knowledge of intensive care unit nurses. It is hoped that through this nursing process and experience, the importance of nursing role functions will be enhanced.