— 生理適應 · MEDIUM · SATA —
一位打石膏的病人，哪些發現應立即報告醫師？（選所有適合的）
Which assessment findings in a client with a casted leg should the nurse report immediately? (Select all that apply.)
- ACapillary refill of 6 seconds in toes✓ 正解腳趾毛細血管回充時間為 6 秒
- BInability to move the toes✓ 正解無法活動趾頭
- CMild itching under the cast石膏下輕微搔癢
- DCool, pale skin on the foot✓ 正解足部皮膚冰冷、蒼白
- ESevere pain unresponsive to medication✓ 正解對藥物無反應的劇烈疼痛
— Explanation · 中文詳解 —
石膏過緊可能導致腔室症候群（Compartment syndrome）。評估重點為 6P：疼痛（Pain）、蒼白（Pallor）、無脈搏（Pulselessness）、感覺異常（Paresthesia）、癱瘓（Paralysis）與過慢的毛細血管回充（Capillary refill >3s）。癢感屬於正常現象，只需注意不可用異物戳刺石膏內部。
A tight cast can lead to compartment syndrome. Assessment focuses on the 6 P's: pain, pallor, pulselessness, paresthesia, paralysis, and prolonged capillary refill (greater than 3 seconds). Itching is a normal phenomenon, and the client should be cautioned not to insert objects inside the cast.
✦ 台美臨床差異
兩地護理師對腔室症候群的評估皆為核心能力，發現異常時皆採緊急通報與減壓處置。