照護一位具自殺問題行為且合併Steven-Johnson Syndrome之精神科病患的護理經驗

Nursing Experience of Caring for a Psychiatric Patient with Suicidal Behavior and Steven-Johnson Syndrome

本篇個案報告描述一位二十歲服役軍人因對部隊環境適應不良，而產生自殺問題行為及急性精神症狀（幻聽）而入院治療之個案，並於住院期間因藥物過敏（Carbamezepine）產生史帝文生-強森症候群（Steven-Johnson syndrome）之護理過程。筆者運用Gordon十一項功能性健康型態作為評估工具，發現主要護理問題為（1）高危險性自我傷害（2）感覺及知覺改變（3）組織完整性受損（4）因應能力失調。住院期間藉由臨床照顧自殺病患之標準給予正向之認知與支持，並運用減輕幻聽之自助式技巧幫助其減少幻覺干擾，另針對Steven-Johnson syndrome所引發的組織完整性受損問題給予隔離及無菌技術照護以避免感染，經妥善照顧及處理後病患出院前已無自殺意念、無幻聽干擾、且生命徵象穩定未有任何Steven-Johnson syndrome所導致之併發症產生。

This case report described the experience of the nursing staff caring for a psychiatric patient with suicidal behavior and acute psychosis (auditory hallucination) in a medical center after joining the army. During this period the patient was diagnosed ? Steven-Johnson syndrome caused by a drug allergy to Carbamezpine . The nursing staff implemented the Gorden health assessment tool to evaluate the patient. The major nursing problems included：(1)High risk for self-mutilation；(2)Sensory-perceptual alteration；(3)Impaired tissue integrity, and (4)Ineffective coping. Cognitive therapy and clinical suicidal standards were used to prevent and treat the patient is suicide behavior. The self-help techniques were also used to reduce auditory hallucination. Besides, The isolation and non-bacterium techniques were used to treat the patient's Steven-Johnson syndrome. The results of the case report were positive. After treatment and excellent care by the nursing staff, the patient had no suicidal ideal, no auditory hallucination, and was free of complications from Steven-Johnson syndrome .