— 降低風險 · MEDIUM · MCQ —
護理師正在評估一位疑似患有深部靜脈栓塞（DVT）的病人。下列哪項評估結果最令人擔憂？
A nurse is assessing a client with a suspected deep vein thrombosis (DVT). Which assessment finding is most concerning?
- ASudden onset of dyspnea and chest pain✓ 正解突發性呼吸困難與胸痛
- BWarmth and redness of the affected limb患肢發紅、皮溫升高
- CA positive Homan's signHoman 徵象陽性
- DUnilateral edema of the calf小腿單側水腫
— Explanation · 中文詳解 —
DVT 病人若突然出現呼吸困難與胸痛，強烈暗示血栓脫落並導致肺栓塞（PE）。肺栓塞是 DVT 最嚴重的併發症，會導致肺循環阻塞與心肺衰竭，屬於需立即急救的危急狀況，遠比局部症狀（如水腫、紅腫）更具生命威脅。
If a patient with DVT suddenly develops dyspnea and chest pain, this strongly suggests that a thrombus has dislodged and caused pulmonary embolism (PE). PE is the most serious complication of DVT, leading to obstruction of the pulmonary circulation and cardiopulmonary failure; it is a critical condition requiring immediate emergency intervention and is far more life-threatening than local symptoms such as edema or redness.
✦ 台美臨床差異
美台臨床對於 DVT 評估一致，皆強調預防 PE 的發生，不再過度依賴 Homan's sign。