一名急性胰臟炎病人出現腹部板狀僵硬與劇烈疼痛。護理師需優先處理下列哪項評估發現？
A client with acute pancreatitis presents with a board-like abdomen and severe pain. Which assessment finding requires the most immediate intervention by the nurse?
- ARespiratory rate 22 breaths/min呼吸頻率 22 次/分
- BBlood pressure 88/50 mmHg✓ 正解血壓 88/50 mmHg
- CAbsent bowel sounds腸鳴音消失
- DSerum amylase 450 U/L血清澱粉酶 450 U/L
急性胰臟炎若併發休克（血壓低、心跳快），代表嚴重的液體流失與發炎反應。ABC 原則中，循環系統（Circulation）的不穩定具有致命性，必須優先處理。板狀腹可能暗示腹膜炎，但血流動力學不穩是導致器官衰竭與死亡的首要危機，故須優先給予輸液穩定血壓。
Hypotension is the most critical finding because it indicates shock and potential organ failure, requiring immediate fluid resuscitation to restore perfusion. While a board-like abdomen suggests peritonitis and elevated amylase is expected in pancreatitis, hemodynamic instability poses the most immediate threat to life. Therefore, addressing the low blood pressure takes priority over other assessments in the context of acute pancreatitis complications.
美國護理師依據緊急處置協定（Standing Order）可先給予靜脈輸液，台灣多需醫師立即看診開立醫囑後才執行。