護理師正在照顧一位急性胰臟炎病人。護理師應預期會出現下列哪些臨床表現？（選所有適合的）
A nurse is caring for a client with acute pancreatitis. Which of the following clinical manifestations should the nurse expect to find? (Select all that apply.)
- AEpigastric pain radiating to the back放射至背部之上腹痛正確答案
- BIncreased serum amylase and lipase levels血清澱粉酶與脂肪酶濃度升高正確答案
- CPain relieved by lying flat on the back仰臥時疼痛緩解
- DCullen's sign (bluish discoloration around the umbilicus)庫倫氏徵象（臍周藍紫色變色）正確答案
- EHypotension and tachycardia低血壓與心搏過速正確答案
- A放射至背部之上腹痛
- B血清澱粉酶與脂肪酶濃度升高
- D庫倫氏徵象（臍周藍紫色變色）
- E低血壓與心搏過速
急性胰臟炎的臨床表現與病理機轉密切相關。核心概念是胰臟消化酵素（如胰蛋白酶）在腺體內被提前活化，導致胰臟「自我消化」。這會引起劇烈的上腹部疼痛，且因為胰臟位於後腹腔，疼痛常放射至背部（A）。實驗室檢查中，澱粉酶（amylase）與脂肪酶（lipase）升高是診斷關鍵（B），其中脂肪酶特異性較高、上升時間也持續較久。在嚴重出血性胰臟炎中，血液可能沿著筋膜滲至皮下，形成臍周瘀斑，即Cullen's sign（D）。此外，發炎反應導致大量液體滲出至第三空間，造成有效循環血量不足，表現為低血壓與代償性心搏過速（E）。選項C錯誤：平躺仰臥會使疼痛加劇，病人通常偏好側臥屈膝（蝦米狀）或坐姿前傾以緩解不適。護理重點在於積極靜脈輸液、止痛與密切監測體液平衡及器官灌流，並在病人可耐受時及早恢復經口進食。
- A · 正確答案放射至背部之上腹痛
胰臟位於後腹腔，發炎引起的劇烈上腹痛常會放射至背部，這是急性胰臟炎最具代表性的疼痛特徵。
- B · 正確答案血清澱粉酶與脂肪酶濃度升高
胰臟受損後，澱粉酶和脂肪酶會大量漏入血液，其數值通常會達到正常上限的三倍以上，具有診斷價值。
- C仰臥時疼痛緩解
仰臥會使發炎的胰臟壓迫到後腹腔神經與腹膜，加劇疼痛。病人通常會透過屈膝側臥或前傾坐姿來減輕壓力。
- D · 正確答案庫倫氏徵象（臍周藍紫色變色）
臍周出現瘀青或藍紫色變化（Cullen's sign）代表發生了出血性胰臟炎，血液滲透至皮下組織，是病情嚴重的指標。
- E · 正確答案低血壓與心搏過速
由於全身性發炎反應與液體蓄積在腹腔（第三空間），會造成血容量不足，進而出現低血壓與代償性的心跳加快。
美國護理強調早期 aggressive hydration（積極輸液）與營養評估，較早考慮腸道營養 (EN) 而非全靜脈營養 (TPN)；台灣臨床則常較長時間維持 NPO 狀態，並依賴血清生化值決定何時開始進食，護理重點放在止痛藥物控制與電解質監測。
English explanation
The clinical manifestations of acute pancreatitis are closely linked to its pathophysiology. The central concept is that pancreatic digestive enzymes (such as trypsin) become prematurely activated within the gland, leading to pancreatic autodigestion. This causes severe epigastric pain, and because the pancreas is located in the retroperitoneum, the pain frequently radiates to the back (A). On laboratory testing, elevation of amylase and lipase is a key diagnostic finding (B). In severe hemorrhagic pancreatitis, blood can track along the fascia to the subcutaneous tissue, producing periumbilical bruising known as Cullen's sign (D). In addition, the inflammatory response causes large volumes of fluid to shift into the third space (peritoneal cavity), resulting in effective hypovolemia that manifests as hypotension and compensatory tachycardia (E). Option C is incorrect because lying supine causes the swollen pancreas to press against the peritoneum and worsens the pain; patients typically prefer a side-lying fetal position or sitting forward to relieve discomfort. Nursing priorities include NPO status, pain control, and close monitoring of fluid balance.
最近修訂：2026-05-17