— 生理適應 · MEDIUM · MCQ —
一名急性胰臟炎病人主訴上腹痛轉移至背部。下列何項護理措施最為優先？
A client with acute pancreatitis reports severe epigastric pain radiating to the back. Which nursing intervention is highest priority?
- AMaintain NPO status維持禁食狀態
- BMonitor blood glucose levels監測血糖濃度
- CAdminister IV morphine as ordered✓ 正解依醫囑給予靜脈注射嗎啡
- DAssess bowel sounds every 4 hours每4小時評估腸鳴音
— Explanation · 中文詳解 —
胰臟炎疼痛源於胰腺腫脹與消化酶刺激，劇痛會導致迷走神經興奮，進而降低心輸出量。疼痛控制可改善病人的氧合與血液動力學狀態。雖然禁食（NPO）是治療基礎，但止痛在 akut 疼痛評估下應優先處理，以免病人因劇痛造成生理代償失調。
Administering prescribed analgesics like IV morphine is the highest priority to manage severe pain, which can trigger sympathetic responses and compromise hemodynamics. Although maintaining NPO status is crucial to rest the pancreas, immediate pain relief takes precedence to prevent physiological stress and complications.
✦ 台美臨床差異
美國護理師常依止痛 protocol 使用 PCA，台灣多需醫師逐次開立醫囑或依疼痛程度評估後執行。