以下哪些評估結果顯示低血容性休克病人的液體復甦有效?(選所有適合的)
Which assessment findings indicate effective fluid resuscitation in a client with hypovolemic shock? (Select all that apply.)
- AUrine output of 40 mL/hr✓ 正解尿量 40 mL/hr
- BSystolic blood pressure of 110 mmHg✓ 正解收縮壓 110 mmHg
- CHeart rate of 85 bpm✓ 正解心率 85 bpm
- DCool and clammy skin皮膚濕冷
- EClear mental status✓ 正解意識清晰
液體復甦有效的指標包括器官灌流恢復與生命徵象穩定。尿量大於 30 mL/hr 代表腎臟灌流改善;收縮壓回升至正常範圍與心率下降至正常(<100 bpm)代表心血管功能改善。神智恢復代表腦部灌流充足。D 選項(皮膚濕冷)是休克的徵象,而非復甦有效的指標。
Indicators of effective fluid resuscitation include restored organ perfusion and stabilized vital signs. A urine output greater than 30 mL/hr reflects improved renal perfusion; restoration of systolic blood pressure to a normal range and a decline in heart rate to normal (<100 bpm) reflect improved cardiovascular function. Restored cognition indicates adequate cerebral perfusion. Option D (cool, clammy skin) is a sign of shock, not an indicator of effective resuscitation.
美國護理師常使用 CVP 或 ScvO2 監測復甦狀況,台灣一般病房主要依賴尿量與血壓監測,ICU 則無顯著差異。