— 降低風險 · MEDIUM · SATA —
哪些評估結果顯示病人正處於體液過多狀態？（選所有適合的）
Which assessment findings indicate that a client is experiencing fluid volume excess? (Select all that apply.)
- ABounding pulse✓ 正解強而有力的脈搏
- BDistended neck veins✓ 正解頸靜脈怒張
- CCrackles in the lungs✓ 正解肺部濕囉音
- DIncreased hemoglobin and hematocrit增加的白血球計數
- EPeripheral edema✓ 正解周邊水腫
— Explanation · 中文詳解 —
體液過多（Fluid Volume Excess, FVE）會導致循環量增加，臨床表現為脈搏強而有力（Bounding pulse）、頸靜脈怒張、肺部囉音（肺水腫早期徵象）及肢體水腫。紅血球相關數值（Hb/Hct）在 FVE 時通常會稀釋而下降，而非上升。
Fluid volume excess increases circulating blood volume, resulting in bounding pulses, distended neck veins, and peripheral edema due to increased capillary hydrostatic pressure. Pulmonary congestion from this excess fluid manifests as crackles in the lungs. Conversely, hemoglobin and hematocrit levels typically decrease due to hemodilution rather than increasing.
✦ 台美臨床差異
兩地護理評估體液過多的標準相同，但在電子病歷紀錄中，美國更依賴每日體重變化趨勢圖來警示醫護人員。