護理師照護一位接受廣效抗生素治療的敗血症病人,下列何項措施對病人管理最關鍵?
A nurse is caring for a client with sepsis who is receiving broad-spectrum antibiotics. Which intervention is most critical for managing this client?
- AMonitor vital signs frequently and assess for signs of organ dysfunction✓ 正解頻繁監測生命徵象並評估器官功能障礙的徵兆
- BAdminister prescribed pain medication給予處方的止痛藥物
- CMaintain strict intake and output records嚴格記錄出入量
- DProvide frequent oral care提供頻繁的口腔護理
敗血症(Sepsis)的臨床核心是全身性發炎反應導致的器官灌流不足(Hypoperfusion)。護理重點在於透過頻繁監測生命徵象(血壓、心率、呼吸、SpO2)及評估器官功能指標(如意識狀態、尿量、皮膚灌流),早期發現敗血性休克(Septic Shock)或多重器官衰竭(MODS)的徵兆,以便及時執行復甦流程。
The clinical core of sepsis is hypoperfusion of organs caused by a systemic inflammatory response. Nursing priorities are frequent monitoring of vital signs (blood pressure, heart rate, respirations, SpO2) and assessment of organ-function indicators (such as level of consciousness, urine output, and skin perfusion) in order to detect early signs of septic shock or multiple organ dysfunction syndrome (MODS) and to allow timely initiation of resuscitation.