— 生理適應 · EASY · MCQ —
一名急性胰臟炎病患出現劇烈腹痛。下列何者為護理師的優先護理措施？
A client with acute pancreatitis presents with severe abdominal pain. Which nursing intervention is the highest priority?
- AEncourage oral intake of clear liquids鼓勵攝取清流質飲食
- BPerform a comprehensive physical assessment進行全面性的身體評估
- CMaintain NPO status and administer IV fluids✓ 正解維持NPO狀態並給予靜脈輸液
- DAdminister oral antacids as ordered依處方給予口服制酸劑
— Explanation · 中文詳解 —
急性胰臟炎治療的核心為「讓胰臟休息」。嚴格禁食（NPO）可抑制胰液分泌，減少胰臟酵素對自身的消化。給予足量靜脈輸液是預防休克及維持電解質平衡的關鍵。A選項口服液體會刺激胰液分泌；D選項口服藥物同樣會引起消化反應；B選項評估雖重要，但需在確保病人不因進食導致病情加重後再進行。
The primary goal in managing acute pancreatitis is to rest the pancreas by strictly maintaining NPO status, which inhibits pancreatic enzyme secretion and reduces autodigestion. Concurrent administration of IV fluids is critical to prevent shock and maintain electrolyte balance, making this intervention the highest priority over assessment or oral intake.
✦ 台美臨床差異
美台臨床皆視 NPO 為標準治療，但在台灣醫院中，護理師需確認醫師開立醫囑後才執行 NPO 較嚴謹。