護理師評估一位疑似左小腿深層靜脈栓塞(DVT)的病人,哪項臨床發現需立即報告醫師?
A nurse is assessing a client with a suspected deep vein thrombosis (DVT) in the left calf. Which clinical finding should the nurse report to the physician immediately?
- ASudden onset of sharp chest pain and dyspnea✓ 正解突發性的尖銳胸痛與呼吸困難
- BLocalized warmth over the calf area小腿區域局部發熱
- CSlight tenderness during palpation觸診時輕微壓痛
- DMild erythema at the site of the clot血栓部位輕微紅斑
深層靜脈栓塞(DVT)最危險的併發症為肺栓塞(Pulmonary Embolism, PE)。當病人出現急性胸痛與呼吸困難,這表示血栓極可能已脫落並隨血液循環進入肺動脈,導致肺部血流受阻。這屬於醫療緊急狀態(Medical emergency),護理師應立即啟動緊急應變程序,確保病人氣道通暢並通知醫師進行搶救。
The most dangerous complication of deep vein thrombosis (DVT) is pulmonary embolism (PE). When the patient develops acute chest pain and dyspnea, this suggests that the thrombus has very likely dislodged and traveled through the circulation into the pulmonary artery, obstructing pulmonary blood flow. This is a medical emergency, and the nurse must immediately initiate emergency response procedures, ensure that the patient's airway is patent, and notify the physician for resuscitation.