— 生理適應 · MEDIUM · MCQ —
一位糖尿病合併周邊血管疾病的病人表示足部疼痛。護理師應優先評估什麼？
A client with diabetes mellitus and peripheral vascular disease reports foot pain. What should the nurse assess first?
- APain scale rating疼痛量表評分
- BSkin integrity皮膚完整性
- CBlood glucose level血糖濃度
- DPedal pulses✓ 正解足背動脈搏動
— Explanation · 中文詳解 —
糖尿病伴隨周邊血管病變時，病人極易產生足部缺血性壞死。疼痛可能是血液循環不足（間歇性跛行或缺血）的警訊。評估末梢脈搏（Pedal pulse）能最快速判斷肢體血流狀況，確保未發生急性血管阻塞，這是保肢的關鍵。
Clients with diabetes mellitus and peripheral vascular disease are at high risk for ischemic necrosis of the feet. Pain may be a warning sign of inadequate circulation (intermittent claudication or ischemia). Assessing pedal pulses is the most rapid way to determine the perfusion status of the limb and ensure that acute vascular occlusion has not occurred, which is key to limb preservation.
✦ 台美臨床差異
美國有專職的傷口照護護理師，台灣此類病人多由一般病房護理師負責傷口評估與轉介至外科。