— 生理適應 · EASY · SATA —
評估疑似盲腸炎病患時，護理師應使用哪些評估技巧？（選所有適合的）
When assessing a patient with suspected appendicitis, which assessment techniques should the nurse use? (Select all that apply.)
- APalpate the RLQ last✓ 正解最後觸診右下象限
- BCheck for rebound tenderness✓ 正解檢查反跳痛
- CPerform deep palpation initially初期進行深層觸診
- DAssess for Rovsing's sign✓ 正解評估羅夫辛氏徵象
- EApply heat to the abdominal area對腹部區域施加熱敷
— Explanation · 中文詳解 —
盲腸炎評估：應從痛點最遠處開始，RLQ（右下腹）最後再觸診，以免引發劇痛。反跳痛（Rebound tenderness）與 Rovsing 徵象（按左下腹引發右下腹痛）皆是診斷指標。絕對不可熱敷，以免盲腸破裂引發腹膜炎。
Assessment of appendicitis: palpation should begin farthest from the point of pain, palpating the right lower quadrant (RLQ) last to avoid provoking severe pain. Rebound tenderness and Rovsing's sign (pressure on the left lower quadrant eliciting pain in the right lower quadrant) are both diagnostic indicators. Heat must never be applied, as it can precipitate appendiceal rupture and peritonitis.
✦ 台美臨床差異
美國護理師常執行這些評估以協助分診；台灣多數檢查由急診醫師執行，護理師較少進行這些主動誘發疼痛的評估。