一名病人入院時出現液體容積過量的臨床表現,下列哪些護理措施是適當的?(選所有適合的)
A client is admitted with clinical manifestations of fluid volume excess. Which nursing interventions are appropriate? (Select all that apply.)
- AAssess breath sounds every 4 hours✓ 正解每 4 小時評估呼吸音
- BAdminister diuretics as prescribed✓ 正解依醫囑給予利尿劑
- CIncrease dietary potassium intake增加飲食中的鉀攝取
- DMonitor daily weights✓ 正解監測每日體重
- EElevate the lower extremities when sitting✓ 正解坐著時抬高下肢
液體容積過量(Fluid Volume Excess)會導致心肺負擔加重,臨床護理重點在於監測肺水腫徵兆與水分平衡。呼吸音評估能及早發現肺部囉音;利尿劑能加速水分排除;每日體重是反映水分滯留最敏感的指標;抬高下肢則可利用重力促進靜脈回流,減輕周邊水腫。護理師需透過這些措施嚴密監測心衰竭或腎功能不全引起的體液超載。
Fluid volume excess increases cardiopulmonary workload, so clinical nursing focuses on monitoring signs of pulmonary edema and fluid balance. Assessing breath sounds allows early detection of crackles; diuretics promote excretion of excess fluid; daily weight is the most sensitive indicator of fluid retention; and elevating the lower extremities uses gravity to promote venous return and reduce peripheral edema. Through these measures the nurse closely monitors volume overload caused by heart failure or renal insufficiency.