護理師評估懷疑體液不足的個案,下列哪些徵象顯示身體正在進行代償?(選所有適合的)
A nurse is assessing a client with suspected fluid volume deficit. Which signs indicate the body is attempting to compensate? (Select all that apply.)
- ATachycardia✓ 正解心搏過速
- BOliguria✓ 正解少尿
- CIncreased capillary refill time✓ 正解毛細血管再充盈時間延長
- DPeripheral edema周邊水腫
- EHypotension低血壓
體液不足時,身體透過交感神經興奮維持心輸出量,導致心跳加速(Tachycardia);腎臟啟動 RAAS 系統減少尿液生成(Oliguria)以保留水分;末梢循環變差(Capillary refill time >3s)。Hypotension 已屬失代償階段,而非代償徵象;Edema 為體液過多所致。
In fluid volume deficit, the body maintains cardiac output through sympathetic stimulation, resulting in tachycardia. The kidneys activate the RAAS system to reduce urine production (oliguria) in order to conserve water, and peripheral circulation worsens (capillary refill time > 3 seconds). Hypotension represents the decompensated stage rather than a compensatory sign, and edema is caused by fluid overload.
台灣護理師常執行精確的出入量紀錄(I/O),美國則較強調對末梢神經與灌流的臨床觀察。