一位慢性腎臟病病人血鉀濃度為 6.5 mEq/L,護理師應優先採取何種措施?
A client with chronic kidney disease (CKD) has a potassium level of 6.5 mEq/L. Which action should the nurse prioritize?
- AAdminister sodium polystyrene sulfonate給予聚苯乙烯磺酸鈉
- BObtain an ECG✓ 正解取得心電圖
- CProvide a low-potassium meal提供低鉀飲食
- DEncourage fluid intake鼓勵攝取水分
高血鉀(Hyperkalemia)濃度達 6.5 mEq/L 是生命威脅。鉀離子過高會影響心肌細胞的去極化與再極化,導致致命的心律不整(如心室顫動)。護理師首要任務是評估病人的心臟電生理狀態,即執行心電圖(ECG)檢查,以觀察有無 T 波尖聳(Peaked T-waves)、QRS 波變寬或 PR 間期延長。安全優先級別中,心臟監測與穩定永遠優於藥物給予。
Hyperkalemia poses an immediate threat of life-threatening cardiac arrhythmias, making electrocardiogram (ECG) monitoring the highest priority to assess cardiac stability. While other interventions like administering potassium-lowering agents or dietary changes are necessary, they address the condition over a longer timeframe compared to the urgent need for cardiac assessment.
在美國,這類高危急症通常會啟動快速反應小組(RRT)或醫師介入,護理師應在取得 ECG 的同時,立即準備 Calcium Gluconate(鈣劑)以穩定心肌膜,這在台灣與美國的緊急處理原則一致。