病人剛完成腹主動脈瘤 (AAA) 修補手術。哪項評估發現最令護理師擔心其腎臟灌流狀況？
A client is recovering from an abdominal aortic aneurysm (AAA) repair. Which finding would most concern the nurse regarding the client's renal perfusion?
- AUrine output of 20 mL/hr for the past 2 hours✓ 正解過去兩小時尿量為 20 mL/hr
- BAbsent pedal pulses足背動脈搏動消失
- CSerum BUN of 18 mg/dL血清 BUN 為 18 mg/dL
- DBlood pressure of 140/80 mmHg血壓為 140/80 mmHg
AAA 修補術中需要夾閉主動脈（Aortic clamping），這會暫時阻斷或減少流向腎動脈的血流。因此，術後急性腎損傷 (AKI) 是重大風險。評估腎灌流最即時、最敏感的臨床指標是每小時尿量。成人的標準應維持在至少 0.5 mL/kg/hr 或約 30 mL/hr。尿量僅 20 mL/hr 持續兩小時顯示腎灌流不足或腎小管受損。BUN 18 處於正常範圍（10-20 mg/dL），無法反映急性變化。足背動脈消失（B）是下肢缺血的徵兆而非腎臟。血壓 140/80（D）尚可接受，雖需控制以防縫合處受壓，但非腎灌流不足的指標。護理師透過監測每小時尿量，能最早發現併發症並啟動補液或藥物治療，達成風險控制目標。
Urine output is the most sensitive and immediate indicator of renal perfusion following abdominal aortic aneurysm repair, as aortic clamping can temporarily reduce blood flow to the kidneys. An output of less than 30 mL/hr suggests acute kidney injury or inadequate renal perfusion requiring prompt intervention. Other findings such as normal BUN levels or stable blood pressure do not reflect acute changes in renal function as directly as urine output.
在美國 ICU 護理中，護理師對尿量不足 30 mL/hr 的敏感度極高，且常有術後補液 Protocol；台灣臨床上則強調記錄每 8 小時總量，對於每小時精確監測的警覺性有時需視單位性質而定。