— 降低風險 · EASY · SATA —
護理師照護一位腹部手術術後的病人。下列哪些發現應立即回報醫師？（選所有適合的）
A nurse is caring for a client who is post-operative from an abdominal surgery. Which of the following findings should be reported to the provider? (Select all that apply.)
- ASerosanguineous drainage on the dressing敷料上有血清血性引流液
- BSudden increase in pain level✓ 正解疼痛程度突然增加
- CEvisceration of the surgical site✓ 正解手術部位內臟脫出
- DPassing flatus排出氣體
- EAbsent bowel sounds腸鳴音消失
— Explanation · 中文詳解 —
術後異常徵象包含傷口內臟外露（Evisceration）及無法解釋的急性劇痛，後者可能隱含腹內出血或吻合口滲漏。A為正常術後反應；D代表腸蠕動恢復為良好徵象；E在術後早期為常見現象，除非伴隨腹脹或腹痛，否則通常無需立即回報。
Abnormal postoperative findings include wound evisceration and unexplained acute severe pain (which may indicate intra-abdominal bleeding or anastomotic leak). A is a normal early postoperative finding; D indicates returning bowel motility (a good sign); E is common in the early postoperative period and only requires reporting if accompanied by distention or pain.
✦ 台美臨床差異
美國醫護對於傷口照護的決策較為去中心化；台灣常見護理師先觀察再決定是否呼叫醫師。