病人剛打上石膏,哪些評估發現應提醒護理師注意潛在併發症?(選所有適合的)
Which assessment findings should alert the nurse to potential complication of a client with a freshly applied cast? (Select all that apply.)
- AInability to move the digits✓ 正解無法活動手指或腳趾
- BPallor of the distal extremity✓ 正解遠端肢體蒼白
- CPulse deficit or absence in the extremity✓ 正解肢體脈搏缺失或消失
- DWarmth of the skin distal to the cast石膏遠端皮膚溫熱
- EPain disproportionate to the injury✓ 正解疼痛程度與傷害不成比例
石膏併發症主要是腔室症候群(Compartment Syndrome),特徵為 5P:疼痛(Pain)、蒼白(Pallor)、脈搏消失(Pulselessness)、感覺異常(Paresthesia)及麻痺(Paralysis)。若出現這些徵兆,顯示神經血管受壓,需立即通知醫師移除或切開石膏。D 選項皮膚溫熱通常代表血液循環良好,非併發症徵兆。
The major complication of a cast is compartment syndrome, characterized by the 5 Ps: pain, pallor, pulselessness, paresthesia, and paralysis. If these signs appear, they indicate neurovascular compromise, and the provider must be notified immediately to bivalve or remove the cast. Option D, warmth of the skin, generally indicates adequate circulation and is not a sign of complication.
美國護理重視神經血管評估(Neurovascular check)的記錄完整性,台灣臨床更常藉由觀察肢體腫脹度及病人主訴來判斷。