— 生理適應 · MEDIUM · SATA —
護理師評估一位疑似全身性感染的患者，應注意哪些發現？（選所有適合的）
A nurse is evaluating a client for signs of systemic infection. Which findings should the nurse note? (Select all that apply.)
- AElevated white blood cell count✓ 正解白血球計數升高
- BFever and chills✓ 正解發燒與畏寒
- CIncreased heart rate✓ 正解心跳速率增加
- DDecreased respiratory rate呼吸速率減慢
- EHypotension✓ 正解低血壓
— Explanation · 中文詳解 —
全身性感染（Sepsis）是身體對感染的過度反應，導致多器官功能受損。臨床表現包含 SIRS 指標：體溫異常（發燒或低體溫）、心搏過速（反映代償性心輸出量增加）、呼吸急促（補償代謝性酸中毒）及白血球異常。當出現低血壓時，代表病人已進入敗血性休克（Septic Shock）階段，屬於危急狀態，護理師需優先維持血液動力學穩定。
Systemic infection manifests through SIRS criteria, including leukocytosis, fever, tachycardia, and hypotension. These findings reflect the immune response, metabolic compensation, and potential progression to septic shock, requiring urgent hemodynamic stabilization.