— 生理適應 · HARD · MCQ —
一名 55 歲高血壓病史個案自述胸部出現劇烈、撕裂感並放射至背部。護理師首要行動為何？
A 55-year-old client with a history of hypertension reports a sudden, severe "tearing" sensation in the chest radiating to the back. Which action is the priority for the nurse?
- AAdminister pain medication給予止痛藥物
- BObtain an ECG取得心電圖
- CPrepare for an emergency echocardiogram準備緊急超音波檢查
- DMonitor blood pressure and maintain a calm environment✓ 正解監測血壓並維持安靜環境
— Explanation · 中文詳解 —
此症狀高度懷疑主動脈剝離（Aortic Dissection）。首要重點在於穩定血流動力學，透過嚴格控制血壓與心跳來減低主動脈壁的剪力（Shearing force），防止剝離擴大。止痛雖然重要，但需先完成血壓控制；ECG 可排除心肌梗塞，但非處理主動脈剝離的首要步驟。
The symptoms suggest an aortic dissection, where the priority is stabilizing hemodynamics to reduce shear stress on the aortic wall. Strict blood pressure and heart rate control are essential to prevent extension of the dissection, taking precedence over pain management or diagnostic imaging.
✦ 台美臨床差異
美國護理師在重症單位常有血壓控制的 Protocol，台灣則需醫師開立醫囑後，由護理師執行降壓藥給予。