護理師正在評估一位有深層靜脈血栓(DVT)的病人。下列哪項評估發現最令人擔憂?
A nurse is assessing a client who has a deep vein thrombosis (DVT). Which assessment finding is most concerning?
- AWarmth and redness of the affected leg患肢溫熱與紅腫
- BSudden onset of shortness of breath and chest pain✓ 正解突發性呼吸困難與胸痛
- CUnilateral leg swelling單側下肢腫脹
- DPain with passive range of motion被動關節活動時疼痛
深層靜脈血栓(DVT)病人最致命的併發症是肺栓塞(Pulmonary Embolism, PE)。當血栓脫落並隨血液循環流向肺部,會導致肺血管阻塞、通氣/灌流比(V/Q mismatch)異常,進而引發嚴重的呼吸窘迫與胸痛。護理師在評估 DVT 病人時,必須具備警覺性,若發現全身性症狀,代表病情已進展為生命威脅(Life-threatening)。
The most lethal complication of Deep Vein Thrombosis (DVT) is Pulmonary Embolism (PE). When a thrombus dislodges and travels with the circulation to the lungs, it can obstruct the pulmonary vasculature and produce a ventilation/perfusion (V/Q) mismatch, leading to severe respiratory distress and chest pain. When assessing a patient with DVT, the nurse must remain vigilant; the appearance of systemic symptoms indicates that the condition has progressed to a life-threatening stage.