病人正從心導管室返回病房。護理師的優先評估是什麼？
A client is returning from a cardiac catheterization. Which assessment is the nurse's priority?
- AGastrointestinal motility胃腸蠕動
- BLevel of orientation意識水準
- CIntake and output for the last 8 hours過去 8 小時的出入量
- DDistal pulses and skin temperature of the affected limb✓ 正解患肢的遠端脈搏和皮膚溫度
心導管檢查（cardiac catheterization）是一種侵入性檢查，通常透過股動脈或橈動脈進行。術後最嚴重的潛在併發症是穿刺部位出血或血腫形成，以及遠端肢體動脈栓塞導致的缺血。這些併發症可能迅速導致肢體缺血甚至壞死，或引起大出血危及生命。因此，護理師在病人返回病房後，必須將評估患肢的循環狀態作為最優先的任務。透過快速而精確的評估，可以及早發現並介入處理潛在的血管併發症，保障病人安全和肢體功能。
Cardiac catheterization is an invasive procedure usually performed via the femoral or radial artery. The most serious potential postprocedure complications are bleeding or hematoma formation at the puncture site, and arterial occlusion in the distal extremity leading to ischemia. These complications can quickly lead to limb ischemia or even necrosis, or to massive bleeding endangering life. Therefore, after the client returns to the ward, the nurse must prioritize assessment of the circulatory status of the affected extremity. A quick and accurate assessment allows early detection and intervention for potential vascular complications, ensuring patient safety and preserving limb function.
心導管檢查後的護理和監測重點，在台灣和美國的臨床實踐中是高度一致的。兩地都強調對穿刺部位出血和遠端肢體循環的優先評估，以確保病人安全並預防嚴重複雜症。在術後護理流程和緊急應變措施上並無顯著差異。