— 生理適應 · MEDIUM · MCQ —
一位病人因高血鉀入院。護理師應優先關注哪項心電圖變化？
A client is admitted with hyperkalemia. Which ECG finding should the nurse prioritize?
- AU wavesU波
- BTall peaked T waves✓ 正解高聳尖銳的T波
- CProlonged PR intervalPR間期延長
- DFlattened P wavesP波扁平
— Explanation · 中文詳解 —
高血鉀會影響心肌電生理，心電圖最早且最具特徵性的變化為高聳 T 波（Tall peaked T waves）。嚴重時會導致 QRS 波變寬與心律不整，進而引發心跳停止。其他選項如 U 波多見於低血鉀，PR 間期延長則較多見於房室傳導阻滯。
Hyperkalemia significantly affects cardiac conduction, with tall, peaked T waves being the earliest and most characteristic electrocardiogram finding. As potassium levels rise, these changes can progress to widened QRS complexes and potentially fatal arrhythmias. Recognizing peaked T waves allows for prompt intervention to lower serum potassium and prevent cardiac arrest.
✦ 台美臨床差異
美國護理師在監測到高鉀心電圖變化時，可依 protocol 執行緊急處置；台灣通常需醫師開立處方。