— 生理適應 · HARD · SATA —
病人術後恢復中，出現哪些徵象暗示可能發生傷口裂開？（選所有適合的）
A client is recovering from an abdominal surgery. Which signs indicate a potential wound dehiscence? (Select all that apply.)
- ASudden gush of serosanguineous fluid✓ 正解突然湧出漿液血性分泌物
- BIncreased pain at the incision site切口處疼痛增加
- CVisible underlying tissues or organs✓ 正解可見深層組織或器官
- DTachycardia and hypotension心搏過速和低血壓
- ESeparation of wound edges✓ 正解傷口邊緣分離
— Explanation · 中文詳解 —
傷口裂開（dehiscence）的典型表徵為傷口邊緣分離，伴隨大量漿液血性液體流出。若更嚴重出現內臟脫出（evisceration），則會可見深層組織或器官。這屬於手術後緊急事件，需立即以生理食鹽水濕紗布覆蓋並通報醫師。
The hallmark of wound dehiscence is separation of the wound edges, often accompanied by a large amount of serosanguineous drainage. In the more severe case of evisceration, the underlying tissues or organs become visible. This is a postoperative emergency, and the nurse must cover the area with saline-moistened gauze and notify the provider immediately.
✦ 台美臨床差異
台美護理師對於 evisceration 的即時處置標準一致，皆強調「覆蓋濕敷料、抬高膝蓋、禁止飲食」。