— 生理適應 · EASY · MCQ —
一位急性胰臟炎病人處於禁食（NPO）狀態並接受靜脈輸液，主訴上腹部劇烈疼痛。護理師應優先進行哪項評估？
A client with acute pancreatitis is NPO and receiving IV fluids. The client reports severe epigastric pain. Which nursing assessment is the priority?
- AObserve for respiratory distress✓ 正解觀察是否有呼吸困難
- BAssess bowel sounds評估腸鳴音
- CMonitor blood glucose levels監測血糖值
- DCheck for signs of internal hemorrhage檢查是否有內出血跡象
— Explanation · 中文詳解 —
急性胰臟炎常因腹腔內發炎反應導致橫膈活動受限或肋膜積水，進而引發呼吸困難。呼吸狀態屬 ABC（Airway, Breathing, Circulation）中的重要環節，護理首重維護氣道與通氣，避免惡化為成人呼吸窘迫症候群（ARDS）。
Acute pancreatitis often causes intra-abdominal inflammation that restricts diaphragmatic movement or produces pleural effusion, leading to respiratory difficulty. Respiratory status is a critical component of the ABCs (Airway, Breathing, Circulation), and the nurse's top priority is to maintain the airway and ventilation, preventing progression to acute respiratory distress syndrome (ARDS).
✦ 台美臨床差異
台美臨床對於胰臟炎病人的呼吸評估準則一致，均強調早期偵測 RDS 徵兆以防插管。