— 生理適應 · MEDIUM · MCQ —
一名急性胰臟炎病人出現劇烈上腹痛並放射至背部。護理師應優先評估下列哪項臨床發現？
A client with acute pancreatitis reports severe epigastric pain radiating to the back. Which clinical finding should the nurse prioritize for immediate assessment?
- AMild jaundice of the sclera鞏膜輕微黃疸
- BDecreased blood pressure and increased heart rate✓ 正解血壓下降和心率增加
- CHyperactive bowel sounds腸鳴音亢進
- DElevated serum amylase and lipase血清澱粉酶和脂肪酶升高
— Explanation · 中文詳解 —
急性胰臟炎可能導致嚴重的血管內液體流失與全身發炎反應症候群（SIRS）。血壓下降伴隨心跳加速（休克徵兆）顯示病人進入低血容積休克狀態，這會直接危及生命，因此必須優先處理。其餘症狀雖然與胰臟炎相關，但沒有立即的致命風險。
Acute pancreatitis can cause significant third-spacing of fluids, leading to hypovolemic shock characterized by decreased blood pressure and increased heart rate. This hemodynamic instability is a life-threatening complication that requires immediate assessment and intervention.
✦ 台美臨床差異
美台臨床對於胰臟炎病人的液體復甦策略一致，皆極重視早期給予大量晶體溶液。