— 降低風險 · HARD · SATA —
護理師應預期在低血容性休克初期觀察到哪些臨床表現？（選所有適合的）
Which assessment findings should a nurse expect to see in a client experiencing early-stage hypovolemic shock? (Select all that apply.)
- ATachycardia✓ 正解心跳過速
- BBradycardia心跳過緩
- CIncreased urine output尿量增加
- DRestlessness or anxiety✓ 正解煩躁或焦慮
- ECool, clammy skin✓ 正解皮膚濕冷
— Explanation · 中文詳解 —
低血容休克初期，身體透過交感神經系統活化來代償。心跳加快以維持心輸出量，皮膚周邊血管收縮導致溼冷，大腦灌流不足會引起早期意識改變如焦慮或躁動。尿量會因腎血流減少而下降，而非增加；心跳變慢通常是休克末期或瀕死的跡象。
Early signs of hypovolemic shock include tachycardia as the sympathetic nervous system attempts to compensate for decreased blood volume, along with restlessness due to cerebral hypoperfusion. Peripheral vasoconstriction also results in cool, clammy skin, whereas bradycardia and increased urine output are not expected in this stage.
✦ 台美臨床差異
美國護理師常依據 Sepsis 或 Shock bundle protocol 直接執行輸液復甦，台灣亦有相關指引但常需醫師同步執行。