— 生理適應 · MEDIUM · MCQ —
護理師為一位手臂全層燒傷（Full-thickness burn）的病人規劃護理，應優先達成的目標為何？
A nurse is planning care for a client with a full-thickness burn on the arm. Which priority nursing goal should be addressed first?
- APsychological support心理支持
- BWound debridement傷口清創
- CFluid resuscitation✓ 正解液體復甦
- DPain management疼痛管理
— Explanation · 中文詳解 —
全層燒傷會導致嚴重的血管通透性增加與液體流失，病人極易陷入低血容性休克。ABC（Airway, Breathing, Circulation）原則中，循環補充液體是燒傷急救的基石，必須在疼痛處理或傷口處置前優先執行。
Full-thickness burns cause severe increases in vascular permeability and fluid loss, putting the client at high risk of hypovolemic shock. Within the ABC (Airway, Breathing, Circulation) framework, circulatory fluid replacement is the cornerstone of burn resuscitation and must be performed before pain management or wound care.
✦ 台美臨床差異
美台燒傷急救皆採用 Parklands 或相關公式進行輸液復甦，原則一致。