一位嚴重燒傷病人被收治於燒傷中心。在初始復甦階段,最優先的護理評估是什麼?
A client with severe burns is admitted to the burn unit. What is the priority nursing assessment during the initial resuscitation phase?
- APresence of infection是否有感染跡象
- BAirway patency and breathing effectiveness✓ 正解呼吸道通暢度與呼吸效能
- CPain level疼痛程度
- DNutritional status營養狀況
燒傷初期,尤其是有吸入性損傷或廣泛燒傷的病人,最危險的威脅是呼吸道水腫和阻塞。因此,確保呼吸道通暢及呼吸有效性是首要任務,必要時需緊急插管。營養、感染和疼痛雖然也很重要,但其處理時機晚於 ABC 的穩定。
During the initial resuscitation phase for a client with severe burns, the priority nursing assessment is ensuring airway patency and breathing effectiveness. This is critical because inhalation injuries and extensive burns can rapidly cause airway edema and obstruction, potentially requiring emergency intubation. While pain management, infection prevention, and nutritional support are important aspects of care, they are secondary to stabilizing the airway and breathing.
美國燒傷中心的團隊照護模式非常成熟,包含整形外科、麻醉科、復健科等;台灣亦有專責燒傷中心,但團隊整合與資源投入程度可能因醫院而異。