# 情境 TMP-SMX第8天的50歲個案出現發燒、倦怠、伴標靶病灶與口腔/結膜黏膜水泡、輕壓即脫皮的疼痛性擴散皮疹。優先護理為何?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375240&lang=zh-tw  
> language: zh-TW  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## 題目

情境 TMP-SMX第8天的50歲個案出現發燒、倦怠、伴標靶病灶與口腔/結膜黏膜水泡、輕壓即脫皮的疼痛性擴散皮疹。優先護理為何?

## 選項

1. 立即停用TMP-SMX並聯絡處方者，準備緊急轉送燒傷單位或ICU；表現符合Stevens-Johnson Syndrome或toxic epidermal necrolysis；保護皮膚與氣道、補充體液電解質、給予止痛、會診皮膚科與眼科；於病歷記錄為永久過敏，未來避用所有含磺胺藥物。 **✔ 正確答案**
2. 給予口服 diphenhydramine 50 mg，並於患處塗抹 triamcinolone 0.1% 乳膏，觀察 4 小時，若無惡化則出院，開立抗組織胺處方並安排 2 天後回診，同時建議繼續完成 TMP-SMX 療程。
3. 安撫個案這些症狀是暫時性的磺胺類藥物反應，給予下一劑排定的 TMP-SMX，於皮疹處塗抹 calamine lotion，記錄發現，每 4 小時監測體溫，若皮膚脫屑加劇則計劃通知開立處方者。
4. 於皮膚病灶塗抹 mupirocin 軟膏以預防繼發性細菌感染，依處方繼續服用 TMP-SMX，安排下週皮膚科會診，指導個案針對口腔潰瘍使用軟毛牙刷，並建議必要時服用 acetaminophen 退燒。

**正確答案: 1**

## 解析

Stevens-Johnson Syndrome (SJS)與toxic epidermal necrolysis (TEN)為連續譜的嚴重皮膚不良反應(SJS30%)。常見誘因：磺胺類、allopurinol、抗癲癇藥(carbamazepine、lamotrigine、phenytoin)、nevirapine、NSAIDs等。發病多於用藥後數日至數週。表現：前驅期發燒、倦怠、咽痛、結膜炎；隨後出現疼痛紅斑至暗色斑、標靶病灶、水泡、Nikolsky徵象陽性(輕壓即脫皮)，並有口、眼、生殖器黏膜侵犯。死亡率高，TEN可達30%。標準護理：(1) 立即停用致敏藥及交叉反應藥；(2) 因皮膚屏障損失似嚴重燒傷，應緊急轉燒傷或ICU；(3) 保護氣道、體液電解質管理、營養、預防感染、止痛、預防角膜疤痕的眼部照護；(4) 會診皮膚科、眼科、必要時加護病房與燒傷外科；(5) 病歷記錄為永久過敏並衛教個案與家屬一生避免磺胺類藥物，建議配戴醫療警示手環。繼續用藥、再給藥、單用抗組織胺、僅塗藥膏皆不安全且危及生命。

## 深入解析

SJS/TEN是皮膚科急症。停藥、轉燒傷或ICU、保護皮膚氣道、終身過敏標記。

## 重要概念

- **Stevens-Johnson Syndrome** — SJS30%體表面積、磺胺/allopurinol/抗癲癇藥、高死亡率
- **Nikolsky sign** — 輕壓即脫皮，見於SJS/TEN/天疱瘡，嚴重剝脫表現
- **burn unit referral** — 廣泛剝脫、體液流失、感染、止痛，治療類似嚴重燒傷

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