一位患有糖尿病的病人被發現意識不清,血糖值為 45 mg/dL。護理師應優先執行哪項介入措施?
A client with diabetes mellitus is found unconscious with a blood glucose level of 45 mg/dL. Which intervention is the priority for the nurse to implement?
- APerform a repeat capillary blood glucose test執行重複的毛細血管血糖檢測
- BAdminister 15 grams of oral carbohydrates給予 15 公克的口服碳水化合物
- CCall for assistance and prepare for intubation請求協助並準備進行氣管內插管
- DAdminister 50% dextrose intravenously✓ 正解靜脈注射 50% 葡萄糖
低血糖導致的意識不清屬於醫療緊急狀況,病人因失去意識,保護性呼吸道反射(如吞嚥)受損,此時給予任何口服物皆有極高的吸入性肺炎風險。護理師應優先確保大腦能量供應並維護呼吸道安全。靜脈注射高濃度葡萄糖(D50W)是恢復意識最迅速的介入措施。臨床優先順序為:穩定生命徵象與恢復供能(ABC原則)。在建立 IV 通路前,若無 IV 設備,應優先考慮給予肌肉注射升糖素(Glucagon)。
An unconscious client with severe hypoglycemia requires immediate restoration of brain energy levels without risking aspiration from oral intake. Intravenous administration of 50% dextrose is the fastest and safest method to reverse hypoglycemia in this scenario. This intervention takes precedence over reassessment or calling for assistance.
在美國臨床,嚴重低血糖時若無 IV 通路,肌肉注射升糖素(Glucagon)是標準首選,而在台灣臨床環境中,護理師通常會優先建立 IV 並給予 D50W,兩者目標一致,但給藥途徑選擇依據現場資源而定。