病人處於低血容性休克的代償期。護理師應預期出現哪項發現?
A client is in the compensatory stage of hypovolemic shock. Which finding should the nurse expect?
- AIncreased urinary output尿量增加
- BDeep, slow respirations深而慢的呼吸
- CDecreased heart rate心率減慢
- DCool, clammy skin✓ 正解皮膚冰冷且潮濕
在低血容性休克(Hypovolemic Shock)的代償期,身體會啟動交感神經系統,透過釋放兒茶酚胺(Catecholamines)來維持重要器官(如心臟與腦部)的血流灌注。血管收縮會導致周邊血管阻力增加,血液會從皮膚、肌肉與腸胃道重新分配至心腦。因此,皮膚會出現因灌流不足導致的蒼白、冰冷且潮濕(Clammy)。護理思路應優先考慮維持循環穩定,並觀察代償機制是否足以維持血壓。
In the compensatory stage of hypovolemic shock, the body activates the sympathetic nervous system, releasing catecholamines to maintain perfusion to vital organs such as the heart and brain. Vasoconstriction increases peripheral vascular resistance, and blood is redistributed away from the skin, muscles, and gastrointestinal tract toward the heart and brain. As a result, the skin becomes pale, cool, and clammy because of decreased perfusion. The nurse's clinical priority is to maintain circulatory stability and observe whether compensatory mechanisms are sufficient to maintain blood pressure.