— 降低風險 · HARD · MCQ —
一位石膏固定肢體的病人，下列哪項評估結果顯示有腔室症候群（compartment syndrome）？
A nurse is assessing a client with a casted extremity. Which assessment finding indicates compartment syndrome?
- AWarmth of the skin distal to the cast石膏遠端皮膚溫熱
- BPain that is unrelieved by medication✓ 正解用藥無法緩解的疼痛
- CCapillary refill time of 2 seconds毛細血管再充盈時間為 2 秒
- DBrisk peripheral pulses周邊脈搏強勁
— Explanation · 中文詳解 —
腔室症候群（Compartment syndrome）的典型表現為「疼痛程度與外傷不成比例（Pain out of proportion）」，且對止痛藥完全無效。當肢體被石膏固定時，若腔室內壓力升高，神經與血管會受壓。除了疼痛，後期徵兆包括蒼白、脈搏減弱、麻木與癱瘓。一旦出現這類疼痛，必須立即通知醫師拆除或修剪石膏，以減輕壓力。
The hallmark of compartment syndrome is 'pain out of proportion to the injury' that is unrelieved by analgesics. When an extremity is immobilized in a cast, rising compartment pressure compresses nerves and vessels. In addition to pain, later signs include pallor, diminished pulses, numbness, and paralysis. Once such pain occurs, the provider must be notified immediately to remove or split the cast to relieve pressure.