# 52歲病人因嚴重急性胰臟炎入院。脂肪酶1,800 U/L，腹痛9/10。哪些護理行動可支持早期辨識嚴重病程並降低併發症風險？請選擇所有適用項目。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372851&lang=zh-tw  
> language: zh-TW  
> subject: Reduction of Risk Potential  
> category: ROR

## 題目

52歲病人因嚴重急性胰臟炎入院。脂肪酶1,800 U/L，腹痛9/10。哪些護理行動可支持早期辨識嚴重病程並降低併發症風險？請選擇所有適用項目。

1

入院時對每位胰臟炎病人投與廣效預防性抗生素以防胰臟膿瘍。

2

監測提示後腹膜出血之Cullen徵象（臍周瘀斑）與Grey-Turner徵象（側腹瘀斑）。

3

啟動積極等張溶液復甦（如LR 5-10 mL/kg/小時），目標每小時尿量≥ 0.5 mL/kg。

4

若有持續嘔吐或腸阻塞，維持嚴格NPO並插鼻胃管低壓間歇抽吸。

5

48小時內連續追蹤檢驗（WBC、BUN、血容比、鈣、血糖、鹼缺、AST、LDH）以套用Ranson準則預估嚴重度。

## 解析

嚴重急性胰臟炎護理優先：必要時NG減壓配合腸休息、48小時連續檢驗套用Ranson、積極等張液復甦（LR優於NS）、監測Cullen與Grey-Turner徵象。選項3錯誤 — 現行ACG指引不建議對急性胰臟炎常規使用預防性抗生素，僅於懷疑感染性壞死時使用。

## 深入解析

嚴重胰臟炎死亡由第三間隙與壞死決定。最有效之兩項護理行動為前24小時LR積極復甦及連續檢驗（BUN趨勢預測力最高）。常規預防性抗生素未降低死亡率且選汰抗藥菌，已不再推薦。

## 臨床情境

**52歲嚴重急性胰臟炎住院**。脂肪酶1,800 U/L（約上限4倍），上腹疼痛9/10放射至背部，噁心嘔吐。前48小時內以**Ranson準則**評估嚴重度。

## 重要概念

- **Ranson準則** — 以入院及48小時時點數值評估急性胰臟炎嚴重度之分數；≥ 3項預測嚴重病程。
- **Cullen / Grey-Turner徵象** — 出血性胰臟炎中後腹膜出血造成之臍周與側腹瘀斑。
- **積極液體復甦** — LR 5-10 mL/kg/小時，依UOP ≥ 0.5 mL/kg/小時、BUN趨勢與血流動力學調整。

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