照顧一位青少女子宮外孕之急診護理經驗

Nursing Experience of An Adolescent Girl with an Ectopic Pregnancy in Emergency Unit

本文描述一位16歲青少女，意外發現罹患子宮外孕至急診求治過程之護理經驗，照護期間為2022年3月25日18：00至21：36，筆者藉由觀察、會談與身體評估等方式收集資料，依Gordon 11項健康功能型態進行整體性評估，確立個案有急性疼痛、體液容積缺失、焦慮等護理問題。護理過程中運用轉移注意力及教導深呼吸放鬆等技巧，協助個案緩解因子宮外孕組織損傷所導致急性疼痛不適之情形；放置生理監測儀器監測生命徵象的變化，並觀察末梢循環的顏色及溫度，同時監測尿量及出血量，以評估個案體液容積缺失的情形，避免休克情形發生；運用圖文及影視資源解釋疾病相關治療，透過傾聽及正向鼓勵等關懷方式，鼓勵個案說出內心感受，引導家屬陪伴後續治療，緩解對於疾病未知及術前的焦慮，貝克焦慮量表（BAI）亦由中度焦慮（24分）降至輕度焦慮（12分）。建議單位能設置簡易且清楚的衛教內容，利用海報張貼、公播、小手冊等方式，宣導青少年正確的避孕措施；也提供衛生署諮詢專線及相關網站等資源，希望個案能藉由此次經歷，學習到正確的知識及保護自己的方式。

This article is the emergency nursing experience of caring for a 16-year-old girl with ectopic pregnancy. The nursing period is from 18:00 to 21:36 on March 25, 2022. The author collects data through observation, interviews, and physical assessment. According to Gordon 11 A holistic assessment of the health function patterns was conducted, and it was established that the case had nursing problems such as acute pain, loss of body fluid volume, and anxiety. During the nursing process, techniques such as diverting attention and teaching deep breathing and relaxation are used to help patients relieve acute pain and discomfort caused by ectopic pregnancy tissue damage; physiological monitoring equipment is placed to monitor changes in vital signs, and the color and temperature of peripheral circulation are monitored. Urine volume and blood loss to assess the loss of body fluid volume of the case and avoid shock; use graphic and video resources to explain disease-related treatment, and encourage the case to express their inner feelings through caring methods such as listening and positive encouragement to guide family members Accompanied by follow-up treatment, the anxiety about the unknown disease and before surgery was relieved, and the Beck Anxiety Inventory (BAI) also decreased from moderate anxiety (24 points) to mild anxiety (12 points). Finally, it is suggested that the unit can set up simple and clear posters, public broadcasts or brochures to publicize correct contraceptive measures for young girls and provide resources such as the consultation line of the Department of Health and related websites. I hope that the case can learn from this experience. Get the right knowledge and ways to protect yourself.