— 生理適應 · HARD · SATA —
急性胰臟炎病人有低血容積風險，護理師應評估哪些徵象？（選所有適合的）
A client with acute pancreatitis is at risk for hypovolemia. Which signs should the nurse assess for? (Select all that apply.)
- AIncreased urine output尿液排出量增加
- BTachycardia✓ 正解心搏過速
- CHypotension✓ 正解低血壓
- DDry mucous membranes✓ 正解黏膜乾燥
- ECapillary refill time > 3 seconds✓ 正解毛細血管再充盈時間＞3秒
— Explanation · 中文詳解 —
急性胰臟炎（Acute pancreatitis）會引發全身性發炎反應，導致微血管通透性增加，引起體液流失至第三空間（Third-spacing），進而引發低血容積（Hypovolemia）。評估重點包括：心跳代償性加速（Tachycardia）、血壓下降（Hypotension）、黏膜乾燥與微血管充盈時間延長（Capillary refill time > 3s），這些都是體液不足的臨床指標。
Acute pancreatitis triggers a systemic inflammatory response, increasing capillary permeability and causing third-spacing of fluid, which leads to hypovolemia. Assessment focuses on compensatory tachycardia, hypotension, dry mucous membranes, and prolonged capillary refill time (>3s)—all clinical indicators of intravascular volume deficit.