— 生理適應 · MEDIUM · SATA —
在接受靜脈點滴的病人中，哪些評估發現應警示護理師可能出現體液過量？（選所有適合的）
Which assessment findings should alert the nurse to potential fluid volume overload in a client receiving IV fluids? (Select all that apply.)
- ABounding peripheral pulses✓ 正解周邊脈搏強而有力
- BDevelopment of a third heart sound (S3)✓ 正解出現第三心音（S3）
- CCrackles in the lung bases✓ 正解肺底部有囉音
- DDecreased blood pressure血壓下降
- EJugular vein distension (JVD)✓ 正解頸靜脈怒張（JVD）
— Explanation · 中文詳解 —
體液過量（Hypervolemia）表現為循環負荷過重，心臟無法負荷導致血液回流受阻與肺部滲漏。S3 心音代表心室舒張早期充盈過快，JVD 反映右心房壓力上升，肺部濕囉音（Crackles）代表肺水腫，跳動強的脈搏則是高血壓與高血容積的表現。低血壓通常是體液不足的表現。
Hypervolemia manifests as circulatory overload, with the heart unable to handle the volume, leading to backflow and pulmonary congestion. An S3 reflects rapid early ventricular filling, JVD reflects elevated right atrial pressure, crackles indicate pulmonary edema, and bounding pulses reflect a volume-overloaded vasculature. Hypotension is typically associated with hypovolemia, not overload.
✦ 台美臨床差異
美國護理師常使用中心靜脈壓 (CVP) 監測，台灣臨床則更依賴聽診與物理檢查評估。