一位有心衰竭病史的病人出現急性呼吸困難及粉紅色泡沫痰,護理師應執行哪些處置?(選所有適合的)
A nurse is caring for a client with a history of heart failure who presents with a sudden onset of dyspnea and pink frothy sputum. Which interventions should the nurse perform? (Select all that apply.)
- APlace the client in a high-Fowler's position✓ 正解將病人置於高福勒氏體位
- BAdminister furosemide as prescribed✓ 正解依醫囑給予呋塞米
- CInitiate IV bolus of normal saline開始靜脈推注正常食鹽水
- DAdminister morphine sulfate✓ 正解給予硫酸嗎啡
- EApply oxygen via non-rebreather mask✓ 正解以非再吸入面罩給氧
核心概念:心臟衰竭(Heart Failure, HF)急性失代償(Acute Decompensation),特別是肺水腫(Pulmonary Edema)的表現。 為何正確答案對: A. 高坐臥位(High-Fowler's position)能利用重力原理,將血液引流至下肢,減少回心血量(Venous return),減輕心臟負荷,同時擴張胸腔,改善呼吸窘迫。 B. 靜脈注射利尿劑(如 Furosemide)能快速促進體內多餘水分和鈉的排出,減輕肺部積液和全身水腫,降低心臟前負荷(Preload)。 D. 嗎啡(Morphine sulfate)是一種鴉片類藥物,除了鎮痛作用,還能引起血管擴張(特別是靜脈),降低心臟前負荷與後負荷(Afterload),並有鎮靜作用,有助於減輕病人的焦慮和呼吸功。 E. 氧氣治療(Oxygen therapy),特別是透過非再呼吸面罩(Non-rebreather mask)以高濃度給予,能迅速改善病人的低血氧(Hypoxia)狀況,是處理急性呼吸衰竭的首要步驟。 為何其他選項錯: C. 生理食鹽水(Normal saline)是等滲透壓溶液,靜脈輸注會增加體內總液體量,加重心臟負擔,對於已處於液體滯留狀態的肺水腫病人,是絕對禁忌。
Immediate interventions for acute pulmonary edema include placing the client in high-Fowler’s position to reduce venous return and ease breathing, administering oxygen to correct hypoxemia, and giving furosemide to promote diuresis and reduce fluid overload. Morphine may also be administered to decrease cardiac preload and alleviate anxiety. Intravenous fluids are contraindicated as they would exacerbate fluid retention and respiratory distress.