— 生理適應 · HARD · SATA —
病人被診斷為抗利尿激素分泌不當症候群(SIADH),護理師應評估到下列哪些臨床表現?(選所有適合的)
A client is diagnosed with SIADH. Which nursing assessments should the nurse anticipate? (Select all that apply.)
- ADilutional hyponatremia✓ 正解稀釋性低血鈉
- BWeight gain without edema✓ 正解無水腫的體重增加
- CIncreased urine specific gravity✓ 正解尿液比重的增加
- DHypernatremia高血鈉
- EDecreased serum osmolality✓ 正解血清滲透壓的降低
— Explanation · 中文詳解 —
SIADH 是抗利尿激素過多,導致水分滯留於體內,進而稀釋血液造成血鈉降低(稀釋性低血鈉)。水分滯留會導致體重增加,但因為液體進入細胞內,通常不會出現明顯水腫。此外,尿液會變得濃縮(比重增加),血漿滲透壓則會下降。
SIADH is caused by excessive antidiuretic hormone, leading to water retention and dilutional hyponatremia. Water retention causes weight gain, but because fluid shifts intracellularly, edema is usually absent. Urine becomes concentrated (increased specific gravity) while serum osmolality falls.
✦ 台美臨床差異
台美皆強調限水及監測 I/O,但美國護理師常需負責頻繁監測血清滲透壓數值並調整給藥時機。