護理師照護一位嚴重燒傷病人。過去 8 小時尿量顯著減少。哪項發現需要立即介入？
A nurse is caring for a client with severe burns. The client's urine output has decreased significantly over the past 8 hours. Which finding requires immediate intervention?
- AUrine specific gravity of 1.030尿液比密 1.030
- BBlood pressure 80/40 mmHg✓ 正解血壓 80/40 mmHg
- CUrine output of 20 mL/hour尿量 20 mL/hour
- DHeart rate 120 bpm心率 120 bpm
燒傷後嚴重脫水和低血容量休克時，血壓會顯著下降。血壓 80/40 mmHg 是休克的嚴重表現，提示器官灌流不足，需要立即處理，如增加輸液速率。雖然尿量少和尿比重高表示脫水，心率快也提示低血容量，但極低的血壓是最危急的。
In severe burns with significant dehydration and hypovolemic shock, blood pressure drops significantly. A blood pressure of 80/40 mmHg is a severe manifestation of shock, indicating inadequate organ perfusion, and requires immediate intervention, such as increasing fluid infusion rates. Although low urine output and high specific gravity also indicate dehydration, and tachycardia suggests hypovolemia, the extremely low blood pressure is the most critical finding.
美國燒傷中心有標準化休克處理流程；台灣則依病情危急度決定介入順序，但血壓是評估休克程度的首要指標。