— 生理適應 · EASY · MCQ —
一位急性胰臟炎病人主訴上腹部劇烈疼痛，護理師應優先進行哪項評估？
A client with acute pancreatitis reports severe epigastric pain. Which nursing assessment is the priority?
- ASkin turgor皮膚彈性
- BRespiratory status✓ 正解呼吸狀況
- CSerum lipase levels血清脂肪酶濃度
- DBowel sounds腸鳴音
— Explanation · 中文詳解 —
急性胰臟炎病人因腹腔內發炎與劇烈疼痛，常導致橫膈移動受限，增加呼吸併發症風險。護理師優先穩定 ABC（氣道、呼吸、循環），評估呼吸頻率與氧合狀況為首要任務。其餘選項雖重要，但非影響生命徵象的立即威脅。
Respiratory status is the priority assessment because severe epigastric pain in acute pancreatitis can cause diaphragmatic splinting, leading to respiratory compromise. Following the ABCs (Airway, Breathing, Circulation), ensuring adequate oxygenation and ventilation takes precedence over other assessments like skin turgor or bowel sounds, which are important but less immediately life-threatening.
✦ 台美臨床差異
美台臨床對於急性胰臟炎疼痛控制均採靜脈止痛，但美國護理師常依 protocol 自行評估並給予 PRN 止痛藥。