— 生理適應 · MEDIUM · MCQ —
一位因胸部、頸部與臉部燒傷的病人入院。護理師的優先評估為何？
A client is admitted with burns on their chest, neck, and face. What is the nurse's priority assessment?
- AInfection prevention預防感染
- BFluid balance and urine output液體平衡與尿液輸出
- CPain management疼痛管理
- DAirway patency✓ 正解氣道通畅
— Explanation · 中文詳解 —
燒傷病人首重 ABC 原則，特別是臉部與頸部燒傷，極易引發吸入性損傷與咽喉水腫。氣道阻塞是燒傷早期最致命的併發症，護理師應評估病人是否有鼻毛燒焦、聲音嘶啞或呼吸困難，確保呼吸道通暢是所有治療的第一步。
Burn care follows the ABC principle, especially with facial and neck burns, which can readily lead to inhalation injury and laryngeal edema. Airway obstruction is the most lethal complication in the early phase of a burn injury. The nurse should assess the client for findings such as singed nasal hairs, hoarseness, and dyspnea; ensuring a patent airway is the first step before any other treatment.
✦ 台美臨床差異
美國急診護理師在燒傷時會更積極執行預防性插管，台灣則會評估後視情況由麻醉科或急診醫師執行。