— 生理適應 · HARD · SATA —
頭部外傷病人意識改變，哪些徵象暗示顱內壓（ICP）增高？（選所有適合的）
A client with a head injury has a change in LOC. Which finding suggests increased intracranial pressure (ICP)? (Select all that apply.)
- ABradycardia✓ 正解心動過緩
- BIrregular respirations✓ 正解呼吸不規則
- CWidening pulse pressure✓ 正解脈壓差變寬
- DTachycardia心動過速
- EHypotension低血壓
— Explanation · 中文詳解 —
庫欣三徵象（Cushing's Triad）是 ICP 增高後的晚期徵象：心跳過慢（Bradycardia）、呼吸不規則（Irregular respirations）、脈搏壓變寬（Widening pulse pressure）。此三者皆為 ICP 壓迫腦幹的危險訊號。
Cushing's triad is a late sign of increased ICP: bradycardia, irregular respirations, and widening pulse pressure. All three are danger signs of brainstem compression by elevated ICP.
✦ 台美臨床差異
美國神經加護病房護理師有特定的 ICP 照護 Bundle；台灣臨床則由醫師依神經外科評估執行。