— 降低風險 · MEDIUM · MCQ —
護理師評估一位低血容性休克病人，下列哪項徵象最必須立即回報？
A nurse is assessing a client for signs of hypovolemic shock. Which finding is the most critical to report?
- APatient is alert and oriented患者意識清晰且定向力完整
- BUrine output of 20 mL/hr✓ 正解尿量為20 mL/hr
- CHeart rate of 88 bpm心率為88 bpm
- DSystolic BP of 110 mmHg收縮壓為110 mmHg
— Explanation · 中文詳解 —
低血容性休克會導致腎臟血流灌流不足，導致尿量減少。成人正常尿量應大於 30 mL/hr，20 mL/hr 代表器官灌流已嚴重不足，是休克惡化的重要早期指標。血壓 110 mmHg 尚在代償範圍內，心跳 88 bpm 也屬穩定。
Hypovolemic shock compromises renal perfusion, leading to oliguria which is a sensitive early indicator of worsening condition. A urine output of 20 mL/hr signifies severe organ hypoperfusion, whereas a systolic blood pressure of 110 mmHg and heart rate of 88 bpm remain within compensated or stable ranges, making the low urine output the most critical finding to report.
✦ 台美臨床差異
美台對於休克病人的監測標準皆極為嚴格，均強調 hourly urine output 為黃金數據。