一位外籍工作者被毒蛇咬傷之急診照護經驗

Emergency Nursing care Experience in a case of a Foreign Worker who Suffered Venomous Snakebite

本文旨描述一位46歲外籍女性於急診施打毒蛇血清的照護經驗。急診醫師依據個案描述毒蛇的外觀及症狀決定先施打抗神經性蛇毒血清，護理團隊密切觀察傷口腫脹惡化，立即與醫師討論更改為抗出血性蛇毒血清，成功阻斷蛇毒繼續侵害組織，彰顯護理照護的重要價值。照顧期間為2022年7月28日00：15至7月28日07：52大夜時段，藉由身體評估、病歷瀏覽、觀察及仲介翻譯收集資料，依據Gordon十一項健康功能型態評估發現有「急性疼痛」、「組織完整性受損」、「焦慮」之健康問題，密切評估腫脹範圍、協助醫師判斷更改蛇毒血清及善用仲介、肢體語言及翻譯軟體提升溝通成效，將資訊轉換菲律賓語幫助個案掌握病況是成功緩解疼痛、打破語言隔閡及降低焦慮的重要關鍵。密切觀察症狀是初始照顧毒蛇咬傷的重要措施，希望藉此經驗能提供急診護理人員照護類似個案之參考。最後，建議醫院系統未來能開發自動比對傷口照片的系統、語言即時轉譯工具，提供一線人員科學化的掌握傷口變化，打破語言隔閡及取得有效的就醫訊息。

We describe the nursing care experience of a female 46-year-old foreign worker treated with antivenom at an emergency department following a venomous snakebite. Based on wound appearance and the patient’s clinical symptoms, the emergency department physician initially elected to administer neurotoxic venom antiserum. In response to close monitoring of progressive wound swelling, the nurse immediately recommended that the physician switch to hemorrhagic venom antiserum, successfully halting tissue damage caused by the venom and underscoring the value of nursing care. The nursing care period was an overnight shift between 00:15 and 07:52 on July 28, 2022. Data was collected through physical examination, medical record review, observation, and mediated translation. Based on Gordon's 11 functional health patterns,“acute pain”,“impaired tissue integrity”, and“anxiety”were identified as health problems. The nurse closely assessed the progress of swelling, assisted the physician in making the switch to hemorrhagic venom antiserum, and effectively used mediation, hand gestures, and translation software to improve patient communication. Translation of information into Tagalog helped the patient understand her condition, which was essential for alleviating pain, overcoming the language barrier, and reducing anxiety. Close monitoring of symptoms is essential in initial management of venomous snakebite. We expect that this experience provides a reference for management of similar cases by emergency nursing personnel. Finally, we recommend that hospitals develop automatic wound image comparison systems and real-time language translation tools to provide frontline personnel with scientific knowledge and tools to monitor wound changes, overcome language barriers, and collect valuable medical information to guide treatment.