Dixon Martha
Homerton University Hospital, London, England.
Nurs Stand. 2018 Feb 28;32(27):44-52. doi: 10.7748/ns.2018.e10870.
Patients in acute settings may present with a variety of signs and symptoms; however, the principles of assessment are applicable to all acutely unwell patients. This article details a case study of a patient who presented to the author's medical ward in a catatonic state, and was assessed using the ABCDE (airway, breathing, circulation, disability, exposure) approach. Catatonia is a disturbed mental state in which a patient exhibits abnormal behaviour, such as the inability to speak and non-responsiveness to stimuli, alongside immobility. Although catatonia is a rare condition, it is important that nurses can identify its signs and symptoms, because it can be fatal if not treated appropriately and rapidly. Thus, it is crucial for nurses to be able to systematically assess acutely unwell patients, including those with catatonia, using the ABCDE approach.
急症患者可能会出现各种体征和症状；然而，评估原则适用于所有急症不适患者。本文详细介绍了一名以紧张症状态入住作者所在内科病房的患者的案例研究，并采用ABCDE（气道、呼吸、循环、残疾、暴露）方法进行评估。紧张症是一种精神紊乱状态，患者会表现出异常行为，如无法说话、对刺激无反应以及不动。尽管紧张症是一种罕见病症，但护士能够识别其体征和症状非常重要，因为如果不及时适当治疗可能会致命。因此，护士能够使用ABCDE方法对急症不适患者，包括患有紧张症的患者进行系统评估至关重要。
