— 生理適應 · HARD · MCQ —
一名燒傷面積達 30% TBSA 的病人，在復甦期的最初 24 小時內，護理師應優先注意什麼？
A client is admitted with burns over 30% of their total body surface area (TBSA). Which finding should the nurse prioritize during the initial 24 hours of resuscitation?
- AUrine output of 15 mL/hour✓ 正解尿量 15 mL/小時
- BBlood pressure of 110/70 mmHg血壓 110/70 mmHg
- CSerum potassium of 4.0 mEq/L血清鉀 4.0 mEq/L
- DHeart rate of 95 beats per minute心率 95 次/分
— Explanation · 中文詳解 —
燒傷初期（Resuscitation phase）最危險的是低血容積休克。每小時尿量（Urine output）是監測組織灌流最敏感的指標。成年人建議維持在 0.5-1.0 mL/kg/hr，約 30-50 mL/hr。15 mL/hr 表示嚴重灌流不足，需調整輸液速率以避免急性腎衰竭。
The most dangerous problem in the early resuscitation phase of burns is hypovolemic shock. Hourly urine output is the most sensitive indicator of tissue perfusion. In adults, the recommended urine output is 0.5-1.0 mL/kg/hr, approximately 30-50 mL/hr. A urine output of 15 mL/hr indicates severely inadequate perfusion, and the infusion rate must be adjusted to avoid acute kidney injury.
✦ 台美臨床差異
台美皆依據 Parkland formula 進行補液，護理師皆負有嚴格監控輸入輸出量的重責。