— 生理適應 · MEDIUM · MCQ —
一位 40% TBSA 的燒傷病患。護理師在最初 24 小時的優先評估為何？
A client is admitted with burns covering 40% of the total body surface area (TBSA). Which priority assessment should the nurse perform in the first 24 hours?
- ARange of motion exercises關節活動運動
- BFluid resuscitation efficacy✓ 正解液體復甦成效
- CWound infection signs傷口感染跡象
- DNutritional intake營養攝取
— Explanation · 中文詳解 —
大面積燒傷（40% TBSA）在最初 24-48 小時內，因微血管通透性增加，會發生嚴重的體液外滲（Capillary leak），導致血管內容積銳減，引發低血容性休克。因此，優先執行液體復甦（Fluid resuscitation，如 Parkland 公式）並監測其有效性（如尿量、血壓），是決定病人存活與預後的關鍵。
In large-area burns (40% TBSA), within the first 24-48 hours, increased capillary permeability causes severe capillary leak, leading to a sharp drop in intravascular volume and triggering hypovolemic shock. Therefore, priority should be given to fluid resuscitation (e.g., using the Parkland formula) and monitoring its effectiveness (such as urine output and blood pressure), which is critical for client survival and prognosis.