# 78歲女性,因重度憂鬱症2週前開始口服escitalopram 10 mg每日一次。新出現頭痛、噁心、意識混亂,家屬表示她在家中跌倒1次。今日血清鈉為124 mEq/L(先前138)。護理師最優先採取的行動為何?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375255&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

78歲女性,因重度憂鬱症2週前開始口服escitalopram 10 mg每日一次。新出現頭痛、噁心、意識混亂,家屬表示她在家中跌倒1次。今日血清鈉為124 mEq/L(先前138)。護理師最優先採取的行動為何?

## 選項

1. 加上hydrochlorothiazide以處理水腫,並維持escitalopram原劑量。
2. 將escitalopram劑量加倍,因為憂鬱症常以身體症狀表現。
3. 以0.9%生理食鹽水250 mL快速靜脈注射立即矯正鈉值。
4. 停用escitalopram並通報處方醫師,執行自由水限制,依醫囑重測血鈉。 **✔ 正確答案**

**正確答案: 4**

## 解析

SSRI相關SIADH低鈉血症常見於老人、女性、低體重與併用利尿劑者,通常於用藥2〜4週內出現。症狀反映腦水腫:頭痛、噁心、意識混亂、跌倒;極低鈉時可能抽搐。優先處置為停用致病藥、通報醫師、自由水限制並監測鈉與神經狀態。加上thiazide會惡化低鈉。加倍劑量增加風險。快速靜注NS有滲透性脫髓鞘風險,並非首選;矯正速率應≤8〜10 mEq/L/24小時。

## 深入解析

新近開始SSRI的老人出現意識混亂或跌倒,必須立即驗鈉並重新檢視用藥 — 不可只當作「憂鬱」或「老化」處理。

## 臨床情境

情境 78歲女性,MDD,2週前開始escitalopram 10 mg口服每日。現有頭痛、噁心、意識混亂與目擊跌倒1次。生命徵象:BP 118/68、HR 82、RR 18、T 36.8°C。檢驗:Na 124 mEq/L(基準138)、K 4.1、Cr 0.8、尿滲透壓480 mOsm/kg、血清滲透壓262 mOsm/kg、尿鈉60 mEq/L → 符合SIADH。無脫水或液體過量徵象。家中用藥:escitalopram、atorvastatin、鈣與維生素D。

## 重要概念

- **SIADH** — 抗利尿激素分泌不當症候群 — 正常容積性低鈉血症,伴濃縮尿(UOsm > SOsm)及尿鈉升高。SSRI/SNRI/carbamazepine/cyclophosphamide為常見藥物誘因。處置為移除誘因加自由水限制(約800〜1000 mL/日)。
- **滲透性脫髓鞘症候群** — 慢性低鈉血症矯正速度超過8〜10 mEq/L/24小時所致的中央橋腦髓鞘溶解。數日後出現構音困難、吞嚥困難、下肢無力與閉鎖症候群。應緩慢矯正,高張食鹽水僅用於嚴重症狀者。
- **SSRI老人注意事項** — 老人較容易出現SSRI相關低鈉血症、跌倒(姿勢性低血壓、嗜睡)、腸胃道出血(尤其併用NSAID)及QT延長(citalopram於60歲以上FDA上限20 mg)。建議測基準Na、心電圖並重新檢視多重用藥。

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