— 生理適應 · EASY · MCQ —
護理師照顧一位新造人工肛門（結腸造口）的病人。下列哪項評估結果代表造口健康？
A nurse is caring for a client with a new colostomy. Which assessment finding indicates that the stoma is healthy?
- ASmall amount of bleeding upon touch觸碰時有少量出血
- BPurple, dusky hue呈紫紺、暗沉色
- CMoist, pinkish-red color✓ 正解濕潤、粉紅色
- DPale, dry appearance蒼白、乾燥外觀
— Explanation · 中文詳解 —
健康的造口應呈現濕潤、玫瑰紅色或粉紅色。D 代表貧血；B 代表組織缺血壞死（紅旗徵象）；A 雖造口組織血管豐富，輕觸會滲血是正常的，但比起 B 的外觀敘述，C 是評估健康程度最全面的指標。題幹要求健康外觀，故選 C 最適當。
A healthy stoma should appear moist and pinkish-red (similar to the buccal mucosa), reflecting good blood supply. Pale and dry suggests anemia or hypoperfusion; purple or dusky indicates ischemia/necrosis—a surgical emergency. Minor bleeding with touch is common because of rich stomal vascularity but is not the defining characteristic of stomal health.
✦ 台美臨床差異
美國護理師常教導病人自我評估造口顏色，台灣則多由造口護理師或病房護理師負責衛教與評估。