— 降低風險 · HARD · SATA —
護理師照護一位心導管術後 2 小時的病人，哪些評估發現應立即回報醫師？（選所有適合的）
Which assessment findings should a nurse report immediately for a client 2 hours post-cardiac catheterization? (Select all that apply.)
- APedal pulses weaker than pre-procedure baseline✓ 正解足部脈搏較術前基準弱
- BSmall bruise at the insertion site插入部位有小瘀青
- CCoolness and pallor in the affected extremity✓ 正解患肢冰冷且蒼白
- DSystolic blood pressure decreased from 130 to 110 mmHg收縮壓從 130 降至 110 mmHg
- ECapillary refill of 4 seconds in the affected foot✓ 正解患肢毛細血管再充盈時間為 4 秒
— Explanation · 中文詳解 —
心導管術後監測重點為肢體循環。脈搏減弱、膚色蒼白、膚溫下降及微血管回充時間延長（大於 3 秒）均暗示動脈受損或血栓阻塞。選項 B 為常見瘀血屬正常；選項 D 血壓輕微波動需監測但非立即危及肢體循環的指標。
The focus of post-cardiac catheterization monitoring is limb circulation. Diminished pulses, pallor, decreased skin temperature, and prolonged capillary refill time (greater than 3 seconds) all suggest arterial injury or thrombotic occlusion. Option B is normal expected bruising; the mild blood pressure fluctuation in option D should be monitored but does not represent an immediate threat to limb circulation.
✦ 台美臨床差異
美護理師對於術後末梢脈搏的評估與紀錄極為嚴格，通常需每小時評估並繪製圖表。