— 生理適應 · MEDIUM · MCQ —
一位急性胰臟炎病患出現嚴重腹痛與嘔吐。護理師最需監測哪種電解質失衡？
A client with acute pancreatitis presents with severe abdominal pain and vomiting. Which electrolyte imbalance is the nurse most concerned about monitoring?
- AHyponatremia低血鈉症
- BHyperkalemia高血鉀症
- CHypermagnesemia高血鎂症
- DHypocalcemia✓ 正解低血鈣症
— Explanation · 中文詳解 —
急性胰臟炎時，脂肪壞死會導致鈣離子與脂肪酸結合產生皂化作用，進而引發低血鈣。這會導致手足抽搐、Trousseau 徵象或 Chvostek 徵象。監測鈣離子是預防致命性心律不整與抽搐的關鍵護理介入，優先級高於其他電解質。
In acute pancreatitis, fat necrosis leads to saponification, in which calcium ions combine with fatty acids, resulting in hypocalcemia. This can cause carpopedal spasm, Trousseau's sign, or Chvostek's sign. Monitoring calcium is a key nursing intervention for preventing fatal arrhythmias and seizures, and takes priority over the other electrolytes.
✦ 台美臨床差異
美台臨床皆重視胰臟炎病患的鈣離子監測，但在台灣較常規化驗與補鈣，美國則更強調針對 Chvostek 徵象的床邊神經評估。