— 生理適應 · HARD · SATA —
一名燒傷面積達 30% 的病人入院。護理師在最初 24 小時內應監控哪些生理變化？（選所有適合的）
A client is admitted with burns on 30% of their body surface area. What physiological changes should the nurse monitor during the first 24 hours? (Select all that apply.)
- AHypovolemia due to fluid shift✓ 正解因體液轉移導致之低血容
- BHyperkalemia due to cell lysis✓ 正解因細胞溶解導致之高血鉀
- CHyponatremia due to fluid loss✓ 正解因體液流失導致之低血鈉
- DMetabolic alkalosis代謝性鹼中毒
- EDecreased cardiac output✓ 正解心輸出量減少
— Explanation · 中文詳解 —
嚴重燒傷初期（復甦期）會發生大規模液體從血管內滲入組織間隙（第三間隙），導致低血容積、心輸出量下降。細胞損傷釋放鉀離子造成高血鉀。體液流失同時伴隨鈉離子丟失，引發低血鈉。代謝性酸中毒較為常見，因組織灌流不足產生乳酸堆積，非鹼中毒。
During the first 24 hours post-burn, massive capillary leakage causes fluid shifts leading to hypovolemia and decreased cardiac output. Cell lysis releases intracellular potassium causing hyperkalemia, while fluid loss results in hyponatremia. Metabolic acidosis, not alkalosis, is expected due to tissue hypoperfusion and lactate accumulation.
✦ 台美臨床差異
美國燒傷中心設有專職護理團隊，採用嚴格的 Parkland 公式補液；台灣則依賴醫師醫囑與一般外科病房照護經驗。