— 生理適應 · MEDIUM · SATA —
下列哪些評估發現應提示護理師注意石膏固定肢體的潛在併發症?(選所有適合的)
Which assessment findings should alert the nurse to potential complications in a client with a casted extremity? (Select all that apply.)
- AParesthesia of the toes✓ 正解腳趾感覺異常
- BCapillary refill of 2 seconds毛細血管再充盈時間為 2 秒
- CUnrelieved pain with analgesics✓ 正解使用止痛藥後疼痛未緩解
- DPallor of the distal extremity✓ 正解遠端肢體蒼白
- EAbsence of distal pulses✓ 正解遠端脈搏消失
— Explanation · 中文詳解 —
石膏固定最危險的併發症為腔室症候群(Compartment Syndrome)。評估重點為「5P」,即痛(Pain)、蒼白(Pallor)、感覺異常(Paresthesia)、脈搏消失(Pulselessness)及麻痺(Paralysis)。若出現這些徵象,顯示組織灌流嚴重受損。
The most dangerous complication of cast immobilization is compartment syndrome. The key assessment is the '5 Ps': pain, pallor, paresthesia, pulselessness, and paralysis. The presence of these signs indicates severely impaired tissue perfusion.
✦ 台美臨床差異
在兩地臨床,護理師發現上述任一徵象均須立即通知醫師,並考慮採取石膏剖開術或筋膜切開術。