— 生理適應 · MEDIUM · SATA —
一位病人呈現低血容性休克徵象，護理師預期會評估到哪些臨床表現？（選所有適合的）
A client presents with signs of hypovolemic shock. Which of the following findings would the nurse expect to assess? (Select all that apply.)
- ATachycardia✓ 正解心跳過速
- BHypotension✓ 正解低血壓
- COliguria✓ 正解少尿
- DWarm, flushed skin皮膚溫熱、潮紅
- EConfusion or altered mental status✓ 正解意識混亂或精神狀態改變
— Explanation · 中文詳解 —
低血容性休克為體液流失導致心輸出量下降。代償機制會出現心跳過快以維持輸出；當代償失效則出現低血壓；腎臟灌流不足導致少尿；腦部缺血導致意識改變。皮膚通常會呈現濕冷蒼白，而非溫暖潮紅（後者多見於敗血性休克）。
Hypovolemic shock results from fluid loss leading to decreased cardiac output, triggering compensatory mechanisms like tachycardia to maintain perfusion. As compensation fails, the client will exhibit hypotension, oliguria due to reduced renal perfusion, and confusion from cerebral ischemia, while skin remains cool and clammy rather than warm.
✦ 台美臨床差異
美國護理師常使用更精確的臨床評分工具（如 MEWS）來判斷休克，台灣則更依賴醫師的臨床經驗與數據監測。