應用Orem理論照顧一位史蒂芬強森症候群患者之護理經驗

Nursing Experience in Caring for a Patient with Stevens-Johnson Syndrome Through the Application of Orem' s Theory

史蒂芬強森症候群（Stevens-JohnsonSyndrome）是一嚴重皮膚損傷急症反應。本文描述一位65歲的個案，在加護病房期間之護理經驗。照護期間自94年8月24曰至94年9月4曰，筆者應用Orem護理理論、經由會談進行持續性、整體性評估，確立其面臨：呼吸道清除功能失效、腸胃組織灌流改變、潛在危險性感染、焦慮、知識缺失（特定的）等健康問題，再藉由完全代償性、部份代償性以及支持教育性護理系統照護個案，提供適切護理措施緩解臨床症狀、穩定生命徵象並加強用藥安全觀念。期以本報告與護理同仁分享SJS照顧經驗，除讓個案能獲得適當照護，提升自我照顧能力，應加強藥物安全衛教宣導，避免二度傷害。Stevens-Johnson Syndrome is a serious skin disease that is life-threatening. This article describes an experience in nursing a 65-year old patient in an intensive care unit. From August 24th to September 4th of 2005, the author applied Orem nursing system theory, including whole compensation, partial compensation and supportive education, in providing a continuous and complete nursing assessment of the patient. This assessment showed that the primary problems experienced by the patient included: ineffective airway clearance; change in G-I tissue perfusion and appetite; risk for potential infection; anxiety; and inadequate knowledge of the disease. The staff provided nursing interventions to alleviate clinical symptoms and signs, to stabilize the physiologic conditions, and to promote the patient’s comprehension of the assigned medications and treatments. We hope to share this experience in taking care of a Stevens-Johnson Syndrome patient with other nursing staff to ensure that patients receive quality care, and improve their self-care capabilities, as well as educate patients about drug safety to avoid secondary harm.