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生理適應 · MEDIUM · SATA

病人診斷為抗利尿激素分泌不當症候群(SIADH),護理計畫應包含哪些內容?(選所有適合的)

A client is diagnosed with SIADH. Which nursing interventions should be included in the care plan? (Select all that apply.)

  • ARestrict fluid intake✓ 正解
    限制液體攝取
  • BEncourage a high-sodium diet✓ 正解
    鼓勵高鈉飲食
  • CMonitor for weight gain✓ 正解
    監測體重增加
  • DAdminister isotonic saline IV bolus
    給予等張鹽水靜脈推注
  • EPlace the client in a semi-Fowler's position
    將病患置於半福勒氏體位(semi-Fowler's position)
Explanation · 中文詳解

SIADH 導致水分滯留、稀釋性低血鈉。治療核心為限水(預防進一步水腫與低血鈉惡化)及補鈉(通常需高張溶液或飲食調整)。每日量體重是評估水分滯留最準確的方法。D 選項錯誤,通常給予高張鹽水而非等張鹽水,以免稀釋情況加劇。

SIADH causes water retention and dilutional hyponatremia. The core of treatment is fluid restriction (to prevent further edema and worsening hyponatremia) and sodium replacement (often requiring hypertonic solutions or dietary adjustment). Daily weight measurement is the most accurate method to evaluate fluid retention. Option D is incorrect: hypertonic saline, rather than isotonic saline, is typically administered, in order to avoid further dilution of serum sodium.

✦ 台美臨床差異

台灣針對 SIADH 的水分監測非常嚴格,美國護理師常有自主決定限水量的權限,台灣多需醫師精確計算。

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