護理師正在衛教一名新診斷為第一型糖尿病的病人關於低血糖的症狀。護理師應包含下列哪些臨床表現?(選所有適合的)
A nurse is teaching a client with newly diagnosed Type 1 Diabetes Mellitus about the signs of hypoglycemia. Which clinical manifestations should the nurse include? (Select all that apply.)
- ATrembling and shakiness✓ 正解顫抖和不穩
- BExcessive thirst and dry mouth過度口渴和口乾
- CIrritability and confusion✓ 正解易怒和意識混亂
- DProfuse sweating (diaphoresis)✓ 正解大量出汗(盜汗)
- EFruity-smelling breath呼氣帶有水果味
低血糖的臨床辨識是糖尿病自我照護的基礎。當血糖低於 70 mg/dL 時,身體會啟動交感神經反應並造成中樞神經系統缺氧症狀。核心概念在於區分『低血糖』與『高血糖/酮酸中毒』。顫抖(A)、躁動/意識混亂(C)以及盜汗(D)是典型的低血糖表現。其中顫抖和盜汗源於腎上腺素釋放,而意識改變則是腦部能量供應不足的警訊。選項 B(口渴、口乾)和 E(水果味氣息)是高血糖或糖尿病酮酸中毒(DKA)的特徵,不應混淆。臨床上,若病人出現 A、C、D 症狀,護理師應遵循『15-15原則』:先給予 15 克簡單糖分,15 分鐘後複測。若不立即處理,低血糖可能進展至抽搐或昏迷,屬於生理適應中的緊急安全問題。
Signs of hypoglycemia include trembling, irritability, confusion, and profuse sweating, which result from sympathetic nervous system activation and decreased glucose availability to the brain. Symptoms such as excessive thirst and fruity-smelling breath are associated with hyperglycemia or diabetic ketoacidosis, not low blood sugar.
美國 NCLEX 考試極度強調病人自我管理的衛教(如 15-15 原則),護理師需具備判斷何時給予葡萄糖膠或升糖素的獨立決策力;台灣臨床上則常伴隨血糖機實測,且對於神智不清者多由醫師決定靜脈推注 50% Dextrose,衛教內容則與國際指引趨於一致。