— 生理適應 · HARD · SATA —
哪些評估結果顯示病患處於敗血症早期階段？（選所有適合的）
Which assessment findings are indicative of early sepsis in a client? (Select all that apply.)
- ATachypnea✓ 正解呼吸過速
- BHyperthermia✓ 正解高燒
- CTachycardia✓ 正解心跳過速
- DHypotension低血壓
- EAltered mental status意識狀態改變
— Explanation · 中文詳解 —
敗血症早期（SIRS 階段）表現為全身性發炎反應，包括心跳加速、呼吸急促及發燒。低血壓與意識混亂通常為敗血性休克（Septic Shock）的徵象，即敗血症演變為不可逆的器官功能不全階段。早期識別並進行液體復甦是關鍵。
Early sepsis (the SIRS stage) presents as a systemic inflammatory response that includes tachycardia, tachypnea, and fever. Hypotension and altered mental status typically indicate progression to septic shock, in which sepsis has evolved into irreversible organ dysfunction. Early recognition and prompt fluid resuscitation are critical.
✦ 台美臨床差異
美國醫院多執行「敗血症組合（Sepsis Bundle）」標準流程，護理師有權優先執行各項檢查；台灣流程依各醫院內科部規章差異大。