— 生理適應 · MEDIUM · MCQ —
一位病人因低血容積休克入院。優先的護理目標為何？
A client is admitted with hypovolemic shock. What is the priority nursing goal?
- AAssess level of consciousness評估意識程度
- BRestore tissue perfusion✓ 正解恢復組織灌流
- CMaintain a warm environment維持溫暖的環境
- DProvide emotional support提供情感支持
— Explanation · 中文詳解 —
低血容積休克（Hypovolemic shock）的病理機轉為循環血量減少，導致心輸出量下降與組織灌流不足。護理的首要目標是「恢復組織灌流」（Restore tissue perfusion），這涵蓋了輸液治療、止血及維持有效循環。若灌流無法恢復，細胞將進入無氧代謝，產生乳酸堆積，最終導致不可逆的多重器官衰竭。其他選項雖為護理工作，但皆為支持性照護，優先級次於維持器官灌流。
The primary nursing goal in hypovolemic shock is to restore tissue perfusion to prevent cellular hypoxia and irreversible organ damage. While assessing consciousness, maintaining warmth, and providing emotional support are important, they are secondary to the immediate physiological need to re-establish adequate blood flow and oxygen delivery to vital organs.