一位病人正經歷糖尿病酮酸中毒(DKA)。護理師應最優先處理哪個評估發現?
A client is experiencing diabetic ketoacidosis (DKA). Which assessment finding is the highest priority for the nurse to address?
- AKussmaul respirations✓ 正解庫斯莫爾呼吸
- BBlood glucose level of 450 mg/dL血糖值 450 mg/dL
- CDehydration with poor skin turgor脫水伴隨皮膚彈性差
- DFruity breath odor果味口臭
DKA 的核心問題是代謝性酸中毒。Kussmaul 呼吸是身體試圖透過過度換氣來代償酸中毒的表現,表示酸中毒已嚴重到影響呼吸模式,需要立即處理。雖然血糖高、果香味呼吸、脫水都是 DKA 的特徵,但呼吸模式改變(Kussmaul breathing)直接反映了嚴重的酸中毒,危及生命。
Kussmaul respirations indicate severe metabolic acidosis, which is the most life-threatening aspect of diabetic ketoacidosis requiring immediate intervention. While hyperglycemia, dehydration, and fruity breath are characteristic findings, the respiratory pattern directly reflects the body's attempt to compensate for acid-base imbalance. Addressing the acidosis and ensuring adequate ventilation takes precedence over managing blood glucose levels or hydration status initially.
美國在 DKA 照護中,會特別關注電解質(特別是鉀離子)的監測與補充;台灣亦同,但可能因檢驗速度與藥物可及性而略有差異。