一位甲狀腺切除術後病人,護理師應立即報告哪些評估發現?(選所有適合的)
A nurse is caring for a client post-thyroidectomy. Which assessment findings should the nurse report immediately? (Select all that apply.)
- APositive Trousseau's sign✓ 正解Trousseau氏徵呈陽性
- BLaryngeal stridor✓ 正解喉鳴音
- CHoarseness of the voice聲音沙啞
- DNumbness around the mouth✓ 正解口周麻木
- EHeart rate of 110 beats per minute心率每分鐘110次
甲狀腺切除術後需特別注意副甲狀腺損傷引起的低血鈣(Trousseau's sign、口周麻木),以及手術併發症引起的氣道阻塞(喉鳴音)。聲音沙啞常見但不一定需要立即回報(多為水腫或喉返神經受刺激),心跳 110 次/分雖需追蹤,但不及氣道阻塞或低血鈣抽搐危急。
After a thyroidectomy, the nurse must be especially alert for hypocalcemia caused by parathyroid injury (Trousseau's sign, perioral numbness) and for airway obstruction caused by surgical complications (laryngeal stridor). Voice hoarseness is common but does not necessarily need to be reported immediately (it is usually due to edema or recurrent laryngeal nerve irritation), and although a heart rate of 110 beats per minute warrants follow-up, it is less urgent than airway obstruction or hypocalcemic tetany.
美國護理師對 Trousseau's 徵象的執行與判斷訓練較紮實;台灣臨床則更依賴抽血數值確認電解質異常。