— 生理適應 · MEDIUM · SATA —
護理師照顧一位頭部創傷的病人，下列哪些發現是顱內壓（ICP）升高的徵象？（選所有適合的）
A nurse is caring for a client with a head injury. Which of the following findings are signs of increased intracranial pressure (ICP)? (Select all that apply.)
- AWidening pulse pressure✓ 正解脈壓差變大
- BBradycardia✓ 正解心動過緩
- CIrregular respirations✓ 正解呼吸不規則
- DTachycardia心動過速
- EPupillary dilation on the side of the injury✓ 正解患側瞳孔擴大
— Explanation · 中文詳解 —
庫欣氏三徵象（Cushing's triad）包含脈壓差增加、心跳過慢、呼吸不規則，這是腦幹壓迫的晚期徵象。此外，瞳孔變化（如患側擴大）也是顱內壓增高常見的神經學惡化指標。心跳過快通常與休克或疼痛有關，非 ICP 升高特徵。
An absence of drainage in the collection device during continuous wound irrigation suggests that the tubing may be obstructed or the system is malfunctioning. This blockage can cause irrigation fluid to accumulate, increasing pressure within the wound cavity and risking tissue ischemia or infection. Immediate intervention is required to clear the obstruction and restore proper drainage flow.
✦ 台美臨床差異
台灣醫院多使用床邊監測儀觀察 ICP 數值；美國部分急診護理師在缺乏設備時更仰賴臨床三徵象判斷。