— 生理適應 · HARD · MCQ —
照護一位全層燒傷病人，前 24 小時的首要介入為何？
A nurse is caring for a client with a full-thickness burn. Which intervention is the priority in the first 24 hours?
- AProvide high-protein diet提供高蛋白飲食
- BPerform a wound debridement進行傷口清創
- CApply topical antibiotics塗抹局部抗生素
- DAdminister fluid resuscitation✓ 正解給予液體復甦治療
— Explanation · 中文詳解 —
燒傷後前 24-48 小時為燒傷休克期，因為體液大量外滲至組織間隙，導致血管內容積銳減。給予足夠的液體復甦（Fluid resuscitation）是防止器官衰竭、維持心輸出量的關鍵，優先度高於傷口照護。
The first 24 to 48 hours post-burn constitute the emergent phase, characterized by massive fluid shifts from the intravascular space to interstitial tissues, leading to hypovolemic shock. Priority nursing intervention is aggressive fluid resuscitation to maintain cardiac output and prevent organ failure, which takes precedence over nutritional support or wound care.
✦ 台美臨床差異
美國燒傷中心有非常嚴格的 Parkland 公式執行流程；台灣臨床亦遵循類似準則，但在資源分配上常由加護病房與燒傷外科共同承擔。