一位疑似頭部外傷的病人正在監測顱內壓 (ICP) 是否升高。護理師應將哪種呼吸型態識別為神經狀態惡化的晚期徵兆？
A client with a suspected head injury is being monitored for increased intracranial pressure (ICP). Which respiratory pattern should the nurse identify as a late sign of deteriorating neurological status?
- AKussmaul respirations庫斯莫耳氏呼吸
- BCheyne-Stokes respirations✓ 正解陳-史氏呼吸
- CEupnea正常呼吸
- DHyperventilation過度換氣
當顱內壓升高影響到腦幹（特別是間腦或大腦半球深處）時，呼吸中樞會受壓迫。Cheyne-Stokes 呼吸（潮式呼吸）表現為呼吸逐漸增快增深，隨後逐漸減慢變淺，最後出現短暫的呼吸暫停，然後循環往復。這是腦部受損嚴重、代謝控制受損的晚期指標。Kussmaul 呼吸（A）與代謝性酸中毒（如 DKA）有關，而非 ICP。過度換氣（D）可能是早期代償，但不如 Cheyne-Stokes 具有定位損傷的預後意義。護理師必須能辨識這些異常節律，以便在病人發生腦疝（Brain Herniation）前及時通報。這屬於減少風險潛力中，對維繫生命徵象（Vital Signs）變化及其背後病生理意義的精確評估。
When increased intracranial pressure affects the brainstem (especially the diencephalon or deep cerebral hemispheres), the respiratory center is compressed. Cheyne-Stokes respirations are characterized by a progressive increase in rate and depth followed by a gradual decrease, ending in a brief period of apnea, and then repeating cyclically. This is a late indicator of severe brain injury and impaired metabolic control. Kussmaul respirations (A) are associated with metabolic acidosis (such as DKA) rather than ICP. Hyperventilation (D) may be an early compensatory response but lacks the localizing prognostic value of Cheyne-Stokes respirations. The nurse must be able to recognize these abnormal patterns in order to notify the team promptly before brain herniation occurs. This falls under the reduction of risk potential, requiring accurate assessment of vital sign changes and the pathophysiology that underlies them.
美國 NCLEX 非常強調「Cushing's Triad」與呼吸型態的關聯；台灣臨床實務中，護理師除觀察呼吸型態外，更依賴於 Glasgow Coma Scale (GCS) 的變化作為首要通報標準。