一位病患正處於休克的補償期(Compensatory stage)。護理師應預期看到哪種生理反應?
A client is in the compensatory stage of shock. Which physiological response should the nurse expect to see?
- ARespiratory acidosis呼吸性酸中毒
- BIncreased urine output尿量增加
- CCool, clammy skin✓ 正解皮膚濕冷
- DDecreased heart rate心率減慢
休克的補償期是身體試圖維持心輸出量與重要器官灌流的階段。核心機轉:交感神經系統(SNS)啟動,釋放兒茶酚胺,導致心跳加快(而非減慢)以增加輸出量;血管收縮以維持血壓。這種血管收縮會減少皮膚與非必要器官的血流,使皮膚呈現冷、濕(Cool, clammy)的狀態。此外,腎臟因灌流減少而啟動 RAAS 系統,導致尿量減少(而非增加)以保留水分。由於代償性過度換氣以排出酸性物質,初期通常呈現呼吸性鹼中毒。當補償失效進入失代償期,才會出現呼吸性酸中毒或血壓崩潰。識別補償期的細微變化(如皮膚濕冷、心跳微升)是防止病患惡化的關鍵。
In the compensatory stage of shock, the sympathetic nervous system activates to maintain cardiac output and perfusion to vital organs. This results in vasoconstriction, which reduces blood flow to the skin, causing it to appear cool and clammy. Additionally, heart rate increases and urine output decreases as the body attempts to preserve fluid volume and blood pressure.
美國 NCLEX 題庫對休克分期的定義非常精確(Compensatory vs Progressive vs Refractory);台灣臨床教育則較多強調整體休克徵象(血壓下降、意識改變),對初期補償期的「細微生理轉變」考核比例略低。