— 降低風險 · HARD · SATA —
護理師照護一位下肢剛打上石膏的病人，哪些發現需要立即回報醫師？（選所有適合的）
A nurse is caring for a client with a new cast on the lower extremity. Which findings should the nurse report to the provider immediately? (Select all that apply.)
- AToes are cool to the touch✓ 正解腳趾觸感冰冷
- BCapillary refill time of 5 seconds✓ 正解微血管充填時間為 5 秒
- CInability to move the toes✓ 正解無法活動腳趾
- DItching under the cast石膏內搔癢
- EPain that is not relieved by analgesics✓ 正解止痛藥無法緩解的疼痛
— Explanation · 中文詳解 —
石膏過緊會導致腔室症候群（Compartment Syndrome），臨床表現為 5P 徵象。溫度冰冷、微血管充填時間過長、無法活動趾頭及止痛藥無效的劇烈疼痛，皆為神經血管損傷的危急指標。搔癢則通常為皮膚乾燥導致，雖不適但非神經血管危急徵象。
A cast that is too tight can lead to compartment syndrome, clinically manifested by the 5 P's. Cold temperature, prolonged capillary refill, inability to move the toes, and severe pain unrelieved by analgesics are all critical indicators of neurovascular compromise. Itching, by contrast, is usually caused by dry skin and, although uncomfortable, is not a critical neurovascular sign.
✦ 台美臨床差異
美國護理師常需記錄 CMS (Circulation, Motion, Sensation) 指標；台灣護理評估亦相同，但更強調觀察石膏邊緣之皮膚壓傷。