護理師照護一位腹膜炎病人。預期會有哪些臨床發現?(選所有適合的)
A nurse is caring for a client with peritonitis. Which clinical findings should the nurse expect? (Select all that apply.)
- ABoard-like abdominal rigidity✓ 正解板狀腹部僵硬
- BHypoactive or absent bowel sounds✓ 正解腸蠕動音減弱或消失
- CRebound tenderness✓ 正解反彈痛
- DSevere abdominal pain✓ 正解嚴重腹痛
- EBradycardia心搏過緩
腹膜炎是腹膜腔的嚴重感染或發炎反應。為了減輕腹痛,腹部肌肉會不自覺地緊繃,形成「板狀腹」;發炎刺激導致腸麻痺,使腸蠕動音消失;腹膜受刺激出現反彈痛(Rebound tenderness)。這些都是腹膜炎的典型腹部體徵,伴隨劇烈腹痛。生理上,身體對發炎的反應通常是心搏過速(Tachycardia)而非過緩。
Peritonitis is a severe infection or inflammatory reaction of the peritoneal cavity. To reduce abdominal pain, the abdominal muscles tense involuntarily, producing a board-like abdomen; inflammation causes paralytic ileus with absent bowel sounds; and peritoneal irritation produces rebound tenderness. These are the classic abdominal signs of peritonitis, accompanied by severe abdominal pain. Physiologically, the body's response to inflammation is typically tachycardia rather than bradycardia.