— 生理適應 · MEDIUM · MCQ —
一位病人因疑似敗血症(Sepsis)入院,下列何者評估為優先?
A client presents with signs of sepsis. Which assessment takes priority?
- AWound status傷口狀況
- BBlood pressure and heart rate✓ 正解血壓和心率
- CTemperature體溫
- DUrine output尿液輸出量
— Explanation · 中文詳解 —
敗血症(Sepsis)的臨床評估必須優先考慮血液動力學(Hemodynamics)。敗血性休克(Septic shock)是敗血症最致命的併發症,其特徵是嚴重的低血壓與組織灌流不足。因此,護理師需優先評估血壓與心跳,以判斷病人是否已進入休克狀態,並及早啟動敗血症急救流程(Sepsis bundle)。
Hemodynamic instability, indicated by changes in blood pressure and heart rate, is the primary concern in sepsis as it signals the progression to septic shock. Assessing these vital signs allows the nurse to evaluate tissue perfusion and initiate timely resuscitation efforts.