— 降低風險 · MEDIUM · MCQ —
護理師評估一名下肢剛打石膏的病人，哪項發現應立即報告？
A nurse is assessing a client with a new cast on the lower extremity. Which finding should be reported immediately?
- AReported itching under the cast主訴石膏下有搔癢感
- BVisible skin edema around the toes腳趾周圍可見皮膚水腫
- CMild warmth of the cast material石膏材質輕微發熱
- DCapillary refill time of 4 seconds✓ 正解毛細血管再充盈時間為 4 秒
— Explanation · 中文詳解 —
下肢石膏病人最嚴重的併發症是腔室症候群（Compartment Syndrome）。正常的微血管回填時間（CRT）應少於 2-3 秒，若延長至 4 秒代表血液灌流不足（perfusion deficit），恐有神經血管壓迫風險，必須立即報告醫師處理。
The most serious complication in a client with a lower-extremity cast is compartment syndrome. A normal capillary refill time (CRT) is less than 2-3 seconds; prolongation to 4 seconds indicates a perfusion deficit and concern for neurovascular compromise, which must be reported to the provider immediately.
✦ 台美臨床差異
美國護理師常直接使用 5P 評估法紀錄；台灣護理師多依循環項目記錄，強調末梢循環與感覺運動評估。