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基本照護與舒適 · MEDIUM · SATA

哪些評估結果顯示病人可能正處於體液容積缺失狀態?(選所有適合的)

Which findings would indicate that a client is experiencing fluid volume deficit? (Select all that apply.)

  • ATachycardia✓ 正解
    心搏過速
  • BDistended neck veins
    頸靜脈怒張
  • COrthostatic hypotension✓ 正解
    姿勢性低血壓
  • DDecreased urine output✓ 正解
    尿量減少
  • EBounding peripheral pulses
    周邊脈搏強而有力
Explanation · 中文詳解

體液容積缺失(fluid volume deficit),又稱低血容(hypovolemia),是指身體因水分和電解質流失而導致細胞外液(extracellular fluid)量減少的狀態。這可能由多種原因引起,如出血、嘔吐、腹瀉、利尿劑使用或水分攝取不足。護理師必須能夠迅速識別體液容積缺失的臨床徵象,因為不及時處理可能導致休克(shock)和器官功能受損。評估結果反映了身體為維持循環灌流而啟動的代償機制,以及組織灌流不足的直接表現。精確的評估是指導後續補液治療和預防嚴重併發症的基礎。

Fluid volume deficit, also known as hypovolemia, refers to a state in which extracellular fluid volume is reduced due to the loss of water and electrolytes. This can result from various causes such as hemorrhage, vomiting, diarrhea, diuretic use, or insufficient fluid intake. The nurse must be able to rapidly identify clinical manifestations of fluid volume deficit, as untimely management can lead to shock and organ dysfunction. Assessment findings reflect both the body's compensatory mechanisms to maintain circulatory perfusion and the direct manifestations of inadequate tissue perfusion. Accurate assessment is the foundation for guiding subsequent fluid replacement therapy and preventing serious complications.

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