— 生理適應 · HARD · SATA —
肝硬化併發腹水的病人，哪些護理措施是適當的？（選所有適合的）
A client with cirrhosis has developed ascites. Which nursing interventions are appropriate? (Select all that apply.)
- AMaintain a low-sodium diet✓ 正解維持低鈉飲食
- BMonitor abdominal girth daily✓ 正解每日監測腹圍
- CAdminister diuretics as prescribed✓ 正解依醫囑給予利尿劑
- DEncourage high-protein intake to replace lost albumin鼓勵攝取高蛋白以補充流失的白蛋白
- EPlace the client in semi-Fowler's position to assist breathing✓ 正解採半坐臥位以協助呼吸
— Explanation · 中文詳解 —
肝硬化腹水主因門脈高壓及低白蛋白血症。限鈉可減少水滯留，每日量腹圍可監測變化，利尿劑用於排除液體，半坐臥位可緩解腹部壓迫導致的呼吸困難。高蛋白飲食需視血氨值而定，嚴重肝病時高蛋白可能誘發肝昏迷，故非首選建議。
Appropriate interventions for ascites include maintaining a low-sodium diet to prevent fluid retention, monitoring abdominal girth daily to track fluid accumulation, and administering prescribed diuretics. Placing the client in semi-Fowler's position aids breathing by reducing abdominal pressure on the diaphragm. High-protein intake is generally restricted or monitored closely in advanced liver disease to prevent hepatic encephalopathy.
✦ 台美臨床差異
台灣醫師對於肝硬化病人的蛋白質攝取標準較為保守，常會依照 Ammonia 指數嚴格控管。