# 個案在最後一次飲酒後18小時入院，出現震顫、出汗、血壓168/96、心跳116及視幻覺。護理師應預期採取哪些處置？（選擇所有適用）

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=374984&lang=zh-tw  
> language: zh-TW  
> subject: Safety and Infection Prevention and Control  
> category: SIPC

## 題目

個案在最後一次飲酒後18小時入院，出現震顫、出汗、血壓168/96、心跳116及視幻覺。護理師應預期採取哪些處置？（選擇所有適用）

1

戒斷期間禁止任何12-step或同儕支持接觸

2

任何含葡萄糖點滴前先給予IV thiamine 100 mg

3

以症狀觸發(CIWA-Ar)protocol給予benzodiazepine

4

頻繁重新定向並保持安靜低刺激環境

5

實施癲癇與跌倒防範

## 解析

根據CIWA-Ar量表採症狀觸發性苯二氮平類藥物給藥，相較於固定時間給藥，可減少苯二氮平總暴露量及住院天數。Thiamine 100 mg IV應在給予葡萄糖前先給予，以預防魏尼克腦病變。抽搐及防跌倒措施可因應戒斷癲癇發作風險（高峰期在24-48小時）。頻繁重新定向並提供低刺激環境可預防情況惡化。中斷同儕支持或12步驟方案是有害的—恢復期支持能改善參與度和治療結果。

## 深入解析

CIWA-Ar:<8微小、8-15輕度、16-20中度、>20重度。DT 48-96小時高峰,未治療死亡率達5%。

## 臨床情境

CIWA-Ar評分22。酒精使用障礙史,每日飲酒12年。無癲癇病史。

## 重要概念

- **CIWA-Ar** — 臨床機構酒精戒斷評估修訂版 — 10項嚴重度量表。
- **酒精性震顫譫妄(DT)** — 重度酒精戒斷 — 意識混亂、自主神經不穩、幻覺。
- **Wernicke腦病** — 硫胺素缺乏 — 眼肌麻痺、共濟失調、意識混亂。葡萄糖無thiamine時誘發。

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