— 生理適應 · HARD · MCQ —
一名急性胰臟炎病患出現板狀腹及腸音消失。護理師優先採取哪項措施？
A client with acute pancreatitis presents with a board-like abdomen and absent bowel sounds. What is the priority nursing intervention?
- APrepare for emergency laparotomy✓ 正解準備緊急剖腹探查術
- BInsert a nasogastric tube to suction插入鼻胃管進行抽吸
- CAdminister parenteral analgesics給予腸外鎮痛劑
- DPerform a physical abdominal assessment進行腹部物理評估
— Explanation · 中文詳解 —
急性胰臟炎出現板狀腹及腸音消失是腹膜炎及腸阻塞的徵象，極可能併發腹腔間室症候群或消化道穿孔。這屬於致命性併發症，需緊急外科手術減壓。B 選項僅能暫時緩解脹氣，無法處理腹膜炎；C 選項雖然需要，但非優先解決生命威脅之處置。
A board-like abdomen with absent bowel sounds in acute pancreatitis suggests peritonitis or ileus, potentially complicated by abdominal compartment syndrome or GI perforation. These are life-threatening complications requiring emergency surgical decompression. NG suction (B) only temporarily relieves distention and does not treat peritonitis; analgesics (C) are needed but secondary; another abdominal exam (D) is not the priority intervention.
✦ 台美臨床差異
美國護理師常依據 SBAR 回報後直接啟動緊急外科會診；台灣臨床流程通常需先報告住院醫師，再由住院醫師會診外科。