— 生理適應 · MEDIUM · SATA —
病人被診斷為腸阻塞，護理師應監測哪些臨床發現？（選所有適合的）
A client is diagnosed with a bowel obstruction. Which clinical findings should the nurse monitor for? (Select all that apply.)
- AAbdominal distention✓ 正解腹部膨脹
- BHyperactive bowel sounds proximal to obstruction✓ 正解阻塞近端腸鳴音亢進
- CVomiting✓ 正解嘔吐
- DProfuse diarrhea大量腹瀉
- EConstant abdominal pain持續性腹痛
— Explanation · 中文詳解 —
腸阻塞導致腸內容物滯留，造成腹脹（Abdominal distention）與噁心嘔吐。在阻塞近端，為了克服阻力，腸蠕動會變得亢進（Hyperactive bowel sounds），隨後才會出現阻塞遠端的靜止狀態。這與腹瀉不同，腹瀉通常會導致脫水，但腸阻塞病人多無法排便。
Bowel obstruction causes retention of intestinal contents, leading to abdominal distention and nausea and vomiting. Proximal to the obstruction, peristalsis becomes hyperactive as the bowel attempts to overcome the resistance, and only later does the segment distal to the obstruction become silent. Unlike diarrhea, which typically causes dehydration, bowel obstruction usually prevents the client from passing stool.
✦ 台美臨床差異
美國護理師常執行鼻胃管的維護與負壓監測；台灣在術後腸阻塞照護中，早期下床與腸道恢復的監測非常重視。