— 生理適應 · MEDIUM · MCQ —
一位急性胰臟炎病患主訴劇烈腹痛。護理師評估中哪項發現需優先告知醫師？
A client with acute pancreatitis presents with severe abdominal pain. Which assessment finding is the highest priority for the nurse to report to the provider?
- AHypoactive bowel sounds腸蠕動減弱
- BSerum amylase level of 500 units/L血清澱粉酶濃度 500 units/L
- CBlood glucose level of 180 mg/dL血糖濃度 180 mg/dL
- DSerum calcium level of 7.2 mg/dL✓ 正解血清鈣濃度 7.2 mg/dL
— Explanation · 中文詳解 —
急性胰臟炎常見低血鈣，因為脂肪壞死釋放脂肪酸與鈣結合。血鈣 < 8.5 mg/dL 會引發手足搐搦、癲癇或心律不整，對病患生命安全威脅最大。A、B、C 雖為異常，但屬於疾病預期內的併發症，優先級低於生命徵象穩定的電解質不平衡。
Hypocalcemia is common in acute pancreatitis because fat necrosis binds calcium with fatty acids. A calcium <8.5 mg/dL can trigger tetany, seizures, or arrhythmias—posing the greatest life threat. A, B, and C are abnormal but expected complications of the disease and are lower priority than an electrolyte imbalance threatening vital function.
✦ 台美臨床差異
美台臨床皆視低血鈣為胰臟炎惡化指標，但在美國護理師常依協定自動啟動嚴密監測並即刻回報，台灣護理師多需醫師確認後處置。