— 生理適應 · MEDIUM · MCQ —
護理師照護一位嚴重燒傷病人。病人的尿量顯著減少。應首先實施哪項護理措施？
A nurse is caring for a client with severe burns. The client's urine output has decreased significantly. Which nursing intervention should be implemented first?
- AIncrease the rate of intravenous fluid infusion✓ 正解增加靜脈輸液的速率
- BNotify the healthcare provider通知醫療提供者
- CAssess the client's blood pressure and heart rate評估病人的血壓和心率
- DAdminister a diuretic給予利尿劑
— Explanation · 中文詳解 —
嚴重燒傷病人早期會出現「體液再分佈」（Fluid shift），血管內液體大量滲透至組織間隙，導致循環血量不足（Hypovolemia），進而引發急性腎衰竭風險，表現為尿量減少。護理師必須依照 Parkland 公式進行液體復甦（Fluid resuscitation），確保組織灌流。調整輸液速度是改善循環最直接的護理介入。
Decreased urine output in severe burn patients indicates hypovolemia due to fluid shifts, making increased intravenous fluid infusion the priority intervention to restore circulating volume. While assessing vital signs is important, immediate fluid resuscitation is critical to prevent acute kidney injury.
✦ 台美臨床差異
美國燒傷中心對於液體復甦採取極為嚴格的監測標準，通常會放置 Foley catheter 以每小時監測尿量（UOP），目標通常為 0.5-1.0 mL/kg/hr。