照顧一位敗血性休克患者執行早期目標導向治療的護理經驗

Nursing Experience of a Patient with Septic Shock Received Early Goal-directed Therapy

10.6530/YYN.2012.6(2).10

李玉雯(Yu-Wen Lee)；林召倩(Chao-Chin Lin)；吳莎莉(Sha-Li Wu)；林佩昭(Pei-Chao Lin)

敗血性休克 ； 早期目標導向治療 ； 組織灌流改變 ； 現存性感染 ； septic shock ； early goal-directed therapy ； altered tissue perfusion ； infection

源遠護理

6卷2期（2012 / 11 / 01）

75 - 83

繁體中文

本文主要描述照顧一位因多重感染導致敗血性休克的老年患者，住進加護病房執行早期目標導向治療的護理經驗。筆者自98年10月22日至11月5日，以身體評估、觀察與家屬會談等方式收集資料，並運用羅氏適應模式進行評估，確立個案有：組織灌流改變、現存性感染與潛在危險性傷害等問題。經過早期目標導向治療合併使用抗生素與控制感染源等相關護理措施，給予個案及家屬關懷與支持，使個案於護理期間組織灌流情形改善、妥善控制血液與傷口及肺部的感染。早期目標導向治療可以減少休克病患因組織灌流不足導致器官衰竭情形發生，評估病患意識、維持病患生命徵象穩定、呼吸道通暢、監測一天輸出入量、皮膚完整性及肢體保暖是重要的護理照護。藉此照護經驗，期能讓臨床護理同仁對敗血症休克執行早期目標導向治療的重要性有更進一步的認識。

This article describes the 2-week intensive care unit nursing care of an elder septic shock patient who received early goal-directed therapy. Patient's data was collected through physical examination, observation and interview with family members using Roy's adaptation model. Patient's health problems were altered tissue perfusion, infection and potential risk for harm. Early goal-directed therapy combined nursing interventions with the use of antibiotics to control source of infection and supporting patient and his family through the treatments. Patient's tissue perfusion and infection in bloodstream, wounds and lung improved during his stay in ICU. Key nursing interventions include assess level of conscious, maintain stable vital signs, maintain patent airway, monitor intake and output, and maintain skin intact and extremities warm. Early goal-directed therapy for shock patients can decrease organ failure due to inadequate tissue perfusion.