照顧一位橫紋肌溶解症病人合併急性腎衰竭之護理經驗

Nursing Experience of a Teenage Patient with Rhabdomyolysis and Acute Kidney Injury

10.6740/NTUHJN.202401_20(1).0013

陳品妤(Pin-Yu Chen)；湯慧心(Hui-Hsin Tang)；蕭偉伶(Wei-Ling Hsiao)

橫紋肌溶解症 ； 急性疼痛 ； 腎組織灌流改變 ； 身體心像紊亂 ； Acute pain ； altered renal tissue perfusion ； body image change ； rhabdomyolysis

臺大護理雜誌

20卷1期（2024 / 01 / 01）

138 - 151

繁體中文;英文

本文為照護一位青少年車禍導致腹內出血、骨折、睪丸創傷，經緊急手術後發生橫紋肌溶解症合併急性腎衰竭之護理經驗，面對突發衝擊造成身心承受極大壓力出現負向情緒引發探討動機，照護期間於2021年10月29日至11月16日，藉由會談、身體評估等收集資料，確立急性疼痛、危險性腎組織灌流改變及身體心像改變等主要健康問題。照護過程中予定量止痛針劑，搭配非藥物措施如按壓傷口、舒適擺位等降低疼痛感；採用實證文獻支持的McMahon評分工具監測橫紋肌溶解症及腎衰竭程度，並維持液體輸注、鹼化尿液、利尿劑以穩定腎組織灌流；因創傷導致睪丸受損，進而擔心同儕異樣眼光及生殖問題，出現哭泣負面情緒，予鼓勵發表內心想法也轉介相關資訊，最後順利轉出加護病房。創傷事故發生讓人措手不及，許多照護需仰賴實證與標準化的照護指引，建議可利用臨床資訊系統自動化醫療系統整合的特點，預先建立相關問題照護指引於該平台，以利第一線醫護人員使用，讓重症照護更加精緻且有效率。

This article describes the nursing experience of a teenage patient with intra-abdominal bleeding, fracture, and testicular trauma resulting from a car accident. After emergency surgery, the patient developed rhabdomyolysis and acute kidney injury. The caring period was from October 29 to November 16, 2021. Data were collected through interviews and physical assessment. The major health problems were identified as acute pain, altered renal tissue perfusion, and body image change. During the care process, acute pain was managed with scheduled analgesic injections and non-pharmacological measures such as wound compression and a comfortable position. The McMahon score, which is supported by empirical literature, was used to assess the severity of rhabdomyolysis and acute kidney injury. In addition, fluid infusion was maintained and urine alkalinization and diuretics were used to stabilize renal tissue perfusion. Owing to the testicular trauma, the patient had negative emotions about peer judgment and reproductive ability. We encouraged him to express his inner thoughts and referred to the relevant information. Finally, the patient was transferred to the intensive care unit. Care for traumatic accidents relies on evidence-based standardized care guidelines. It is recommended that the integration capabilities of clinical information systems be leveraged to proactively establish guidelines for frequent problems. This enhances the precision and efficiency of critical care.