— 生理適應 · MEDIUM · MCQ —
一位肝硬化伴隨腹水的病患。下列哪項護理措施在液體管理上最為適當？
A patient with liver cirrhosis presents with ascites. Which nursing intervention is most appropriate for fluid management?
- AMonitor daily weights✓ 正解監測每日體重
- BAdminister daily IV bolus給予每日靜脈推注
- CEncourage high protein intake to shift fluid鼓勵高蛋白飲食以轉移液體
- DMeasure abdominal girth every 48 hours每48小時測量腹圍
— Explanation · 中文詳解 —
肝硬化腹水病人的體液管理指標為「每日體重」。腹圍測量雖重要，但每日精確的體重變化是評估水分滯留最敏感的指標。IV Bolus 會加重腹水；高蛋白不一定能解決腹水，需視肝昏迷情況；腹圍每日測量比 48 小時測量更具意義。
Monitor daily weights as they are the most accurate and sensitive indicator of fluid gain or loss in ascites. Abdominal girth measurements should also be taken daily for consistency rather than every 48 hours.
✦ 台美臨床差異
台美臨床對於腹水處理皆傾向利尿劑與限制鈉攝取；在美國，護理師常執行腹水穿刺（Paracentesis）後的護理與觀察。