一名 45 歲急性胰臟炎病患主訴背部放射狀劇烈疼痛。護理師首要評估指標為何？
A 45-year-old client with a history of acute pancreatitis reports sudden, sharp, radiating pain to the back. Which nursing assessment is the priority?
- ABlood pressure and heart rate✓ 正解血壓與心率
- BUrine output via indwelling catheter導尿管之尿量
- CSerum lipase levels血清脂酶濃度
- DBowel sounds腸鳴音
急性胰臟炎（acute pancreatitis）常導致嚴重的全身性發炎反應，進而引發血管通透性增加與第三空間體液流失，病人極易出現低血容性休克（hypovolemic shock）。劇烈疼痛、背部放射痛皆為臨床表徵，但評估生命徵象（血壓、心跳）是護理師的第一優先行動，以判定病人是否處於休克狀態。休克是威脅生命的急症，必須透過生命徵象的變化來早期偵測並處理。
Hemodynamic stability is the priority assessment because acute pancreatitis can cause severe systemic inflammation and third-spacing of fluids, leading rapidly to hypovolemic shock. Monitoring blood pressure and heart rate allows the nurse to detect early signs of circulatory collapse before other symptoms become irreversible. Although urine output and serum lipase are important, vital signs provide the most immediate data on the client's survival status.