一位 45 歲急性胰臟炎患者，血壓為 88/50 mmHg，心率 118 bpm，尿量減少。護理師應優先執行哪項處置？
A 45-year-old client with acute pancreatitis presents with a blood pressure of 88/50 mmHg, heart rate 118 bpm, and decreased urine output. Which intervention should the nurse prioritize?
- AAdminister IV morphine for pain relief給予靜脈注射嗎啡以緩解疼痛
- BObtain blood samples for serum amylase and lipase抽取血液樣本檢測血清澱粉酶和脂肪酶
- CInsert a nasogastric tube for decompression插入鼻胃管以進行減壓
- DInitiate rapid IV fluid resuscitation with normal saline✓ 正解開始以生理食鹽水進行快速靜脈補液復甦
急性胰臟炎最致命的早期併發症是低血容性休克。由於嚴重的發炎反應導致血管通透性增加，液體會滲出到後腹腔與第三空間（Third spacing），導致有效循環血量急遽下降。此病人的徵象（低血壓、心跳過快、尿量減少）已明確顯示處於休克狀態。根據 ABC 與循環優先原則，建立靜脈通路並進行大量補液（Resuscitation）是穩定生命徵象的第一步。止痛（A）雖然在胰臟炎護理中非常重要，但在血壓不穩定的情況下，嗎啡等鴉片類藥物可能加重低血壓。鼻胃管引流（C）用於緩解腸阻塞或嘔吐，非緊急救命措施。實驗室檢查（B）是用於診斷，不能解決當前的休克危急。臨床思路上，護理師應先救命（穩定灌流），再治病（緩解症狀）。
The most life-threatening early complication of acute pancreatitis is hypovolemic shock. Severe inflammation increases vascular permeability, causing fluid to leak into the retroperitoneum and third space, leading to a rapid decline in effective circulating volume. This client's findings (hypotension, tachycardia, decreased urine output) clearly indicate shock. Based on the ABC and circulatory priority principles, establishing IV access and providing aggressive fluid resuscitation are the first steps to stabilize vital signs. Pain control (A), while very important in pancreatitis nursing care, may worsen hypotension when blood pressure is unstable, as opioids such as morphine can lower blood pressure further. NG decompression (C) is used to relieve ileus or vomiting and is not an emergency life-saving measure. Laboratory studies (B) are used for diagnosis and cannot resolve the present shock crisis. Clinically, the nurse must first save the life (stabilize perfusion), then treat the disease (relieve symptoms).
在美國護理實務中，護理師通常根據醫院的休克處置協定（Standing Orders/Protocols），在醫師尚未到場前即可先開啟兩條粗針大口徑靜脈管路並開始補液。在台灣，雖然急診護理師具備高度警覺，但法律上通常仍需先獲得口頭或書面醫囑才能開始輸液，儘管在危急狀況下會有彈性處理。