— 降低風險 · MEDIUM · MCQ —
護理師監測急性胰臟炎病人。應優先將哪項發現視為致命性併發症的徵兆？
The nurse is monitoring a client with acute pancreatitis. Which finding should the nurse prioritize as a sign of a life-threatening complication?
- AEpigastric pain radiating to the back上腹痛放射至背部
- BAbsent bowel sounds腸音消失
- CNausea and vomiting噁心與嘔吐
- DBluish discoloration around the umbilicus✓ 正解臍周出現藍紫色色素沉著
— Explanation · 中文詳解 —
臍周青紫（Cullen's sign）或腰部青紫（Grey Turner's sign）代表後腹腔出血與壞死性胰臟炎。這是一種極為嚴重的併發症，預示病人可能發生低血容積休克。A 與 C 是急性胰臟炎的常見症狀；B 代表麻痺性腸阻塞，雖需注意但急迫性低於出血徵象。
Periumbilical bruising (Cullen's sign) or flank bruising (Grey Turner's sign) reflects retroperitoneal hemorrhage and necrotizing pancreatitis. This is an extremely serious complication that signals impending hypovolemic shock. A and C are common symptoms of acute pancreatitis; B represents paralytic ileus, which requires attention but is less urgent than signs of hemorrhage.
✦ 台美臨床差異
美國 NCLEX 非常喜歡考 Cullen's sign 與 Trousseau's sign（低鈣）；台灣臨床則更常監測 Amylase/Lipase 數值。