— 生理適應 · EASY · SATA —
護理師照顧一位新造口病人。下列哪些徵象顯示造口癒合良好？（選所有適合的）
A nurse is caring for a client with a new colostomy. Which findings indicate the stoma is healing appropriately? (Select all that apply.)
- AStoma is moist and pink✓ 正解造口濕潤且呈粉紅色
- BSmall amount of bleeding upon contact✓ 正解接觸時有少量出血
- CStoma appears purple or dusky造口呈現紫色或蒼白
- DSkin around the stoma is intact✓ 正解造口周圍皮膚完整
- EStoma protrudes slightly from the abdomen✓ 正解造口略微突出於腹部
— Explanation · 中文詳解 —
健康的造口應呈現濕潤粉紅色（像口腔黏膜），因血管豐富，清潔時有輕微滲血是正常的。造口應稍微突出腹部以利排泄物進入袋中。若造口呈現紫色或暗色（選項 C），則提示組織缺血或壞死，是嚴重的危險徵兆，須立即通報醫師。
A healthy stoma should appear moist and pink (similar to oral mucosa) and, because it is highly vascular, slight bleeding during cleaning is normal. The stoma should protrude slightly from the abdomen so that stool can pass into the appliance. If the stoma appears purple or dusky (option C), this indicates tissue ischemia or necrosis, a serious warning sign that must be reported to the provider immediately.
✦ 台美臨床差異
美國造口護理師 (WOCN) 介入較早；台灣多由病房護理師負責，必要時會照會造口治療師。