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生理適應 · HARD · SATA

病人診斷為抗利尿激素分泌異常症候群(SIADH),哪些護理措施是適當的?(選所有適合的)

A client is diagnosed with SIADH (Syndrome of Inappropriate Antidiuretic Hormone). Which nursing interventions are appropriate? (Select all that apply.)

  • ARestrict fluid intake✓ 正解
    限制水分攝取
  • BAdminister hypertonic saline as prescribed✓ 正解
    依醫囑給予高張性食鹽水
  • CMonitor for signs of hyponatremia✓ 正解
    監測低血鈉徵象
  • DEncourage increased dietary sodium intake✓ 正解
    鼓勵增加飲食中鈉的攝取
  • EPlace the client in a high-Fowler's position
    將病人置於高福勒氏體位
Explanation · 中文詳解

SIADH 導致 ADH 分泌過多,引起水分滯留與稀釋性低血鈉。護理重點在於:1. 限水(避免水分進一步堆積);2. 給予高張鹽水(修正血鈉);3. 監測低血鈉症狀(如意識改變、癲癇);4. 補鈉。高 Fowler's 位對 SIADH 病人並無直接治療效果,通常用於呼吸困難病人。

SIADH causes excessive water retention and dilutional hyponatremia due to inappropriate antidiuretic hormone secretion. Appropriate interventions include restricting fluid intake to prevent further accumulation, administering hypertonic saline to correct severe hyponatremia, monitoring for signs of low sodium such as confusion or seizures, and encouraging dietary sodium to counteract dilution. High-Fowler's position is not a standard treatment for this condition.

✦ 台美臨床差異

美國醫護對於 SIADH 的限水管理非常嚴謹(甚至需鎖定水罐),台灣臨床護理師亦採嚴格控水,但常需向家屬衛教為何不能飲水。

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