病人因糖尿病酮酸中毒(DKA)入院,護理師預期會發現哪些評估結果?(選所有適合的)
A client is admitted with diabetic ketoacidosis (DKA). Which findings should the nurse expect? (Select all that apply.)
- AKussmaul respirations✓ 正解庫斯莫爾氏呼吸 (Kussmaul respirations)
- BFruity breath odor✓ 正解水果味口臭
- CHyperglycemia✓ 正解高血糖
- DWeight gain體重增加
- EMetabolic alkalosis代謝性鹼中毒
DKA 病人因酸中毒出現代償性的深快呼吸(Kussmaul respirations),酮體分解產生爛蘋果味氣息(Fruity breath)。血糖明顯升高(Hyperglycemia),且因高滲透性利尿與嘔吐,會出現脫水與體重減輕,酸鹼值為代謝性酸中毒,非鹼中毒。
Clients with diabetic ketoacidosis (DKA) typically present with severe hyperglycemia, which is the hallmark of the condition. The body compensates for metabolic acidosis through Kussmaul respirations, and the accumulation of acetone produces a characteristic fruity breath odor. Dehydration from osmotic diuresis and vomiting leads to weight loss rather than gain, and the acid-base imbalance is metabolic acidosis, not alkalosis.
美國醫院針對 DKA 有標準化的 insulin drip protocol,護理師需緊密進行 hourly blood glucose 調整;台灣模式與之相似。