— 生理適應 · MEDIUM · MCQ —
護理師正在照護一位嚴重燒傷的病人。哪項發現提示了體液復甦的潛在併發症？
A nurse is caring for a client with severe burns. Which finding indicates a potential complication of fluid resuscitation?
- AIncreased blood pressure血壓升高
- BRapid heart rate心跳過速
- CDecreased respiratory rate呼吸頻率減慢
- DDecreased urine output✓ 正解尿量減少
— Explanation · 中文詳解 —
燒傷病人體液復甦的目標是維持足夠的血容量和組織灌流，但也可能因輸液過量或細胞內液轉移至細胞外空間，導致體液滯留。尿量顯著減少（少尿）可能是體液過量或腎灌流不足的徵兆，需要評估。心率快、血壓低表示體液不足；血壓升高、呼吸速率下降通常非主要體液復甦併發症。
Fluid resuscitation in burn patients aims to maintain tissue perfusion, but complications can arise from fluid overload or inadequate response. Decreased urine output is a key indicator of either insufficient renal perfusion or fluid volume issues, necessitating immediate assessment and adjustment of the resuscitation plan.
✦ 台美臨床差異
美國的燒傷中心有嚴格的體液計算公式（如 Parkland formula），並依據尿量、血壓等動態調整；台灣的照護也遵循類似原則，但燒傷中心的資源與團隊經驗影響甚鉅。