一位病人接受甲狀腺切除術後 6 小時，向護理師主訴嘴唇周圍及指尖有「刺痛感」。護理師應優先採取哪項措施？
A nurse is assessing a client who is 6 hours post-thyroidectomy. The client reports a 'tingling feeling' around the mouth and in the fingertips. Which action should the nurse take first?
- AAssess the client's surgical dressing for bleeding評估病人手術敷料是否有出血
- BCheck the client's serum calcium level and Chvostek's sign檢查病人血清鈣濃度及Chvostek氏徵象正確答案
- CEncourage the client to use an incentive spirometer鼓勵病人使用誘發性肺量計
- DAdminister a prescribed analgesic for postoperative pain給予處方止痛藥以緩解術後疼痛
- B檢查病人血清鈣濃度及Chvostek氏徵象
甲狀腺切除術最常見且嚴重的潛在併發症之一是副甲狀腺受損或誤切，導致副甲狀腺素（PTH）分泌不足，進而引發急性低血鈣（Hypocalcemia）。刺痛感（Paresthesia）是神經肌肉興奮性增高的早期徵兆。護理師必須立即評估低血鈣的徵象，如 Chvostek's sign（叩擊耳前神經引起面部抽動）或 Trousseau's sign（血壓計充氣引起手部痙攣）。這屬於風險預防（Reduction of Risk Potential）中的「併發症評估」。雖然出血（A）也是重要評估，但針對『刺痛感』這一特定主訴，低血鈣是最直接的疑似原因。止痛（D）和肺部護理（C）在此時並非優先動作，因為低血鈣可能引發喉頭痙攣（Laryngospasm）甚至癲癇發作，具有生命威脅。
- A評估病人手術敷料是否有出血
檢查敷料是甲狀腺手術後的常規評估以排除血腫壓迫氣管，但刺痛感並非出血的典型症狀，應優先考慮電解質異常。
- B · 正確答案檢查病人血清鈣濃度及Chvostek氏徵象
刺痛感是低血鈣引發神經肌肉過度興奮的早期警訊，檢查 Chvostek 氏徵象能快速評估是否發生副甲狀腺損傷併發症。
- C鼓勵病人使用誘發性肺量計
誘發性肺量計用於預防術後肺塌陷，與病人主訴的感覺異常無關，在面對急性併發症時不具備優先順位。
- D給予處方止痛藥以緩解術後疼痛
給予止痛藥能緩解疼痛，但無法解決神經肌肉刺痛的根本原因，甚至可能掩蓋病情惡化的臨床徵兆。
在美國護理實務中，對於甲狀腺術後的低血鈣，護理師通常有預設的 Protocol (Standing Orders) 可立即抽血並在確認後補充 Calcium Gluconate；台灣則多需先通報住院醫師，待醫師床邊評估後才開立檢驗與補鈣醫囑。
English explanation
One of the most common and serious potential complications of thyroidectomy is damage to or inadvertent removal of the parathyroid glands, leading to insufficient parathyroid hormone (PTH) secretion and acute hypocalcemia. Paresthesia (a tingling sensation) is an early sign of increased neuromuscular excitability. The nurse must immediately assess for signs of hypocalcemia, such as Chvostek's sign (twitching of the face when the facial nerve is tapped in front of the ear) or Trousseau's sign (carpal spasm induced by blood pressure cuff inflation). This falls under reduction of risk potential and assessment for complications. Although postoperative bleeding (A) is also an important consideration, hypocalcemia is the most direct suspected cause of the specific complaint of tingling. Analgesia (D) and pulmonary care (C) are not priorities at this time, because hypocalcemia can precipitate life-threatening laryngospasm or seizures.
最近修訂：2026-09-30