護理師評估一位有深部靜脈栓塞(DVT)風險的病人,哪些臨床表現與 DVT 相關?(選所有適合的)
A nurse is assessing a client who has a risk for deep vein thrombosis (DVT). Which findings are associated with DVT? (Select all that apply.)
- ACalf pain or tenderness✓ 正解小腿疼痛或壓痛
- BUnilateral edema✓ 正解單側水腫
- CWarmth in the affected extremity✓ 正解患肢局部發熱
- DDiminished pedal pulses足背脈搏減弱
- ECyanosis of the toes腳趾發紺
深部靜脈栓塞(DVT)的典型臨床表現源於靜脈血液回流受阻與局部發炎反應。Virchow's triad(血液滯留、血管內皮損傷、血液高凝狀態)導致受影響肢體出現單側水腫、因靜脈壓升高引發的疼痛或壓痛,以及因發炎與血液鬱積導致的局部皮膚溫度升高。這些症狀通常是單側的,若為雙側水腫則需考慮心衰竭等全身性因素。
The typical clinical manifestations of deep vein thrombosis (DVT) result from obstructed venous return and local inflammatory response. Virchow's triad (venous stasis, vascular endothelial injury, and hypercoagulability) leads to unilateral edema of the affected limb, pain or tenderness caused by elevated venous pressure, and local warmth from inflammation and venous congestion. These manifestations are typically unilateral; bilateral edema should raise concern for systemic causes such as heart failure.