— 生理適應 · HARD · SATA —
一名肝硬化合併門脈高壓的病人，護理師應評估到哪些徵象？（選所有適合的）
A client with cirrhosis is admitted with signs of portal hypertension. Which findings should the nurse expect? (Select all that apply.)
- AAscites✓ 正解腹水
- BEsophageal varices✓ 正解食道靜脈曲張
- CCaput medusae✓ 正解水母頭
- DSplenomegaly✓ 正解脾腫大
- EPeripheral edema✓ 正解周邊水腫
— Explanation · 中文詳解 —
門脈高壓是肝硬化常見併發症，導致血流回流受阻。A：腹水因靜水壓增加與白蛋白減少；B：側支循環形成導致食道靜脈曲張；C：腹壁靜脈曲張；D：脾臟淤血造成腫大；E：低白蛋白血症與高醛固酮造成水腫。所有選項皆符合。
Portal hypertension is a common complication of liver cirrhosis and obstructs venous return. A: Ascites results from increased hydrostatic pressure and decreased albumin; B: Formation of collateral circulation leads to esophageal varices; C: Caput medusae (abdominal wall varices) develop; D: Splenic congestion produces splenomegaly; E: Hypoalbuminemia and elevated aldosterone produce edema. All options are correct.
✦ 台美臨床差異
在台灣，肝硬化合併症的衛教常涉及肝炎防治與飲食建議；美國則更著重於酒精戒斷與長期營養支持計畫。