護理師監測 T6 水平急性脊髓損傷病人的自主神經反射異常 (AD)。哪些發現顯示此狀況?(選所有適合的)
A nurse is monitoring a client with an acute spinal cord injury at the level of T6. Which findings would suggest autonomic dysreflexia? (Select all that apply.)
- ASudden severe headache✓ 正解突發性劇烈頭痛
- BFlushing of the face and neck✓ 正解臉部與頸部潮紅
- CExtreme hypertension✓ 正解極度高血壓
- DTachycardia of 120 beats per minute每分鐘 120 次的心搏過速
- ENasal congestion✓ 正解鼻塞
自主神經反射異常 (Autonomic Dysreflexia, AD) 是一種發生在脊髓損傷 (Spinal Cord Injury, SCI) T6 節段或更高部位的病人身上的危及生命併發症。它是由於損傷平面以下的有害刺激(如膀胱脹尿、糞便嵌塞、壓瘡等)觸發了無法控制的交感神經反應。由於脊髓損傷阻斷了上行抑制性訊號,導致損傷平面以下血管劇烈收縮,引起嚴重高血壓,而損傷平面以上則因代償性副交感神經活動而出現臉部潮紅、出汗、鼻塞和心搏過緩。及早辨識 AD 症狀並移除刺激是防止腦出血、癲癇或死亡的關鍵。
Autonomic dysreflexia is a life-threatening complication in clients with spinal cord injuries at T6 or higher, triggered by noxious stimuli below the injury level. Symptoms include sudden severe hypertension, which causes a pounding headache, facial flushing, nasal congestion, and sweating above the injury site. Unlike tachycardia, bradycardia is the typical compensatory response to the extreme hypertension.