— 降低風險 · HARD · SATA —
一位腹部手術後的病人疑似發生內出血，下列哪些臨床表徵支持此診斷？（選所有適合的）
A client is diagnosed with suspected internal hemorrhage post-abdominal surgery. Which findings support this diagnosis? (Select all that apply.)
- ATachycardia✓ 正解心跳過速
- BHypotension✓ 正解低血壓
- CCool, clammy skin✓ 正解皮膚濕冷
- DIncreased urine output尿量增加
- ERestlessness or anxiety✓ 正解煩躁不安或焦慮
— Explanation · 中文詳解 —
腹部手術後疑似內出血，會引發低血容性休克。初期徵兆為交感神經代償反應：心跳加快（Tachycardia）、焦慮不安（Restlessness/Anxiety）；隨著失血加重，病人出現周邊血管收縮，皮膚變冷濕黏，最後血壓下降（Hypotension）。尿量減少（Oliguria）則反映腎臟灌流不足。護理師應密切監測這些徵兆，並準備緊急輸液或輸血。
Suspected internal hemorrhage post-abdominal surgery can lead to hypovolemic shock, characterized by tachycardia, hypotension, cool clammy skin, and restlessness as compensatory mechanisms fail. These signs reflect decreased cardiac output and peripheral vasoconstriction, whereas urine output typically decreases rather than increases due to reduced renal perfusion.