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生理適應 · HARD · SATA

護理師計畫照顧一位急性胰臟炎病人,應包含哪些護理措施?(選所有適合的)

A nurse is preparing to care for a client with acute pancreatitis. Which interventions should the nurse include in the plan of care? (Select all that apply.)

  • AMaintain NPO status to rest the pancreas✓ 正解
    維持禁食狀態以讓胰臟休息
  • BAdminister IV fluids to maintain hydration✓ 正解
    給予靜脈輸液以維持水分平衡
  • CProvide a high-fat diet to prevent malnutrition
    提供高脂飲食以預防營養不良
  • DAssess pain level and administer analgesics as ordered✓ 正解
    評估疼痛程度並依指示給予止痛藥
  • EMonitor blood glucose levels frequently✓ 正解
    頻繁監測血糖水平
Explanation · 中文詳解

急性胰臟炎(Acute pancreatitis)的治療核心在於「讓胰臟休息(Pancreatic rest)」,以減少胰液分泌,進而降低胰臟組織的自體消化。治療重點包含禁食(NPO)、積極輸液復甦以維持組織灌流,以及嚴密的疼痛管理。此外,由於胰臟發炎可能影響胰島素分泌,導致代謝異常,監測血糖(Blood glucose)是必要的護理常規。臨床思路應優先評估病人狀況並維持生理穩定,避免任何刺激胰液分泌的行為。

Maintaining NPO status rests the pancreas by reducing enzyme secretion, while IV fluids address third-spacing and dehydration. Pain management is critical due to the severity of inflammation, and frequent blood glucose monitoring is necessary because pancreatic dysfunction can impair insulin production. A high-fat diet is contraindicated as it stimulates pancreatic secretion and exacerbates symptoms.

✦ 台美臨床差異

美國醫院臨床對於胰臟炎的止痛藥給予,目前傾向於儘早使用 IV Opioids(如 Morphine 或 Hydromorphone),過去認為 Morphine 會導致 Oddi 括約肌痙攣的疑慮,在現代實證醫學中已較少被視為禁忌。

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