— 生理適應 · MEDIUM · MCQ —
一位病患下肢剛打上石膏，下列哪項評估結果需要護理師立即介入？
Which assessment finding in a client with a newly applied cast to the lower extremity requires immediate nursing intervention?
- AClient reports itching inside the cast病人報告石膏內搔癢
- BCapillary refill time of 3 seconds in the toes腳趾毛細血管再充盈時間為 3 秒
- CToes that are cool to the touch and pale✓ 正解腳趾觸感冰冷且蒼白
- DMild edema around the cast edges石膏邊緣輕微水腫
— Explanation · 中文詳解 —
石膏邊緣或內部的過緊會導致神經血管受壓，表現為「5P」徵象（Pain, Pallor, Pulselessness, Paresthesia, Paralysis）。腳趾蒼白且冰冷明顯暗示循環受阻，若不立即處理，可能導致組織壞死，屬於急症，需立即聯繫醫師檢查石膏是否過緊或需切開。
An excessively tight cast edge or interior can compress the neurovascular bundle and manifest as the "5 Ps" (pain, pallor, pulselessness, paresthesia, paralysis). Pale and cool toes strongly suggest impaired circulation; if not addressed immediately, tissue necrosis may occur. This is an emergency requiring prompt notification of the provider to assess whether the cast is too tight or requires bivalving.
✦ 台美臨床差異
兩地護理師對於石膏護理（Neurovascular check）的標準一致，均需具備識別 Compartment syndrome 徵象的能力。