— 生理適應 · EASY · MCQ —
一位頭部受傷的病患出現顱內壓（ICP）增高的症狀。護理師應維持何種姿勢？
A client with a head injury exhibits signs of increased intracranial pressure (ICP). Which position should the nurse maintain?
- AHead of bed elevated 30 degrees✓ 正解抬高床頭30度
- BSupine with head flat仰臥且頭部放平
- CTrendelenburg position特倫德倫堡氏姿勢（頭低腳高位）
- DProne position俯臥姿勢
— Explanation · 中文詳解 —
顱內壓增高時，保持頭部抬高 30 度有助於靜脈回流，降低腦部充血。Trendelenburg（頭低腳高）會使血液大量湧入腦部，導致 ICP 急劇升高。平躺也會影響靜脈回流，Prone 姿勢則會壓迫胸腔並影響呼吸。此措施簡單且能有效緩解 ICP 壓力。
Elevating the head of the bed to 30 degrees promotes venous drainage from the cranium and reduces intracranial pressure. Trendelenburg increases cerebral blood volume; flat supine impedes venous return; prone restricts chest expansion and indirectly increases ICP.
✦ 台美臨床差異
美台對 ICP 的床頭高度設置觀點一致，均為臨床標準程序。