— 生理適應 · EASY · MCQ —
一位急性胰臟炎病人正接受靜脈輸液並禁食，下列哪項評估發現需要護理師立即處置？
A client with acute pancreatitis is receiving IV fluids and is NPO. Which assessment finding requires the nurse's immediate intervention?
- APain rated 6 out of 10疼痛評分為 10 分中的 6 分
- BHypoactive bowel sounds腸蠕動減弱
- CBlood glucose 150 mg/dL血糖 150 mg/dL
- DMuscle twitching and positive Trousseau's sign✓ 正解肌肉抽搐和 Trousseau 氏徵象陽性
— Explanation · 中文詳解 —
急性胰臟炎常因鈣離子與壞死脂肪酸結合導致低血鈣。Trousseau's sign 陽性及肌肉抽搐是嚴重低血鈣徵象，可能引發喉頭痙攣或心律不整，需優先處理。高血糖常見於胰島受損，疼痛為預期症狀，腸鳴音減弱也屬常見生理改變。
Acute pancreatitis can lead to hypocalcemia because fatty acids released from necrotic tissue bind with calcium. Muscle twitching and a positive Trousseau’s sign indicate severe hypocalcemia, which poses an immediate risk for laryngospasm and cardiac arrhythmias. This finding requires urgent intervention with calcium replacement to prevent life-threatening complications.
✦ 台美臨床差異
台美均將低血鈣視為危急值，但美國護理師常有給予緊急鈣補充的 protocol，台灣通常需先通知醫師開立醫囑。