— 生理適應 · MEDIUM · MCQ —
一位急性胰臟炎病患主訴劇烈且持續的上腹痛。下列何者為最優先的護理措施？
A client with acute pancreatitis reports severe, constant epigastric pain. Which nursing intervention is the highest priority?
- AMonitor serum amylase and lipase levels監測血清澱粉酶和脂肪酶濃度
- BAdminister IV analgesics as ordered依醫囑給予靜脈注射鎮痛劑
- CMaintain NPO status✓ 正解維持禁食狀態
- DEncourage deep breathing exercises鼓勵進行深呼吸運動
— Explanation · 中文詳解 —
急性胰臟炎的治療核心在於減少胰臟消化酶分泌，以利組織修復，故禁食（NPO）並配合靜脈輸液是穩定病情的首要條件。止痛固然重要，但若未執行禁食，進食會加劇胰臟分泌，導致病情惡化，因此禁食屬於生理適應中最緊急的處置。
The cornerstone of treatment for acute pancreatitis is to reduce pancreatic enzyme secretion to allow tissue healing; therefore, maintaining NPO status combined with IV fluids is the first priority for stabilization. Pain management is important, but if NPO is not maintained, eating will stimulate pancreatic secretion and worsen the disease; thus, NPO is the most urgent physiological intervention.
✦ 台美臨床差異
美國護理師常依據醫囑執行禁食後的進階處置（如給予腸內營養），台灣臨床則多嚴格執行至醫師開立醫囑。