對於一位穿戴長腿石膏的病人，哪項評估結果需要護理師立即介入？
Which assessment finding in a client with a long-leg cast requires immediate intervention by the nurse?
- AThe client requires more opioid analgesics than 6 hours ago病人比 6 小時前需要更多的鴉片類鎮痛劑正確答案
- BThe client reports itching under the cast病人報告石膏下有搔癢感
- CThe toes are cool to the touch but pink in color腳趾觸摸起來冰冷但顏色呈粉紅色
- DThere is a small amount of serosanguinous drainage on the cast石膏上有少量漿液血性滲出液
- A病人比 6 小時前需要更多的鴉片類鎮痛劑
腔室症候群（compartment syndrome）的早期辨識，為石膏固定後最危險的併發症。 為何正解A對：疼痛在給予止痛藥後仍持續加劇、鴉片類需求量較6小時前增加，代表疼痛與傷勢不成比例（pain out of proportion），這是腔室症候群最早的徵兆，須立即通報。 為何其他選項錯：B石膏下搔癢是常見不適，應教導病人勿將異物伸入石膏內搔抓以免皮膚破損，但不需立即處置。C腳趾偏涼但顏色紅潤，代表末梢循環仍可，須持續觀察並比較兩側。D石膏上少量血清血樣滲液屬預期範圍，可圈記範圍與時間追蹤。 臨床推理：腔室症候群的五P（疼痛、蒼白、無脈、感覺異常、麻痺）中，無脈是最晚出現的徵象；等到無脈時神經肌肉損傷多已不可逆，故須從疼痛性質的改變提早察覺。
- A · 正確答案病人比 6 小時前需要更多的鴉片類鎮痛劑
止痛藥無法緩解且持續加劇的疼痛是腔室症候群的頭號警訊，代表組織壓力上升導致缺血，必須立即通知醫師處理。
- B病人報告石膏下有搔癢感
石膏內癢感雖然令病人困擾，但不會造成生命或肢體威脅，可教導使用冷風吹入緩解，非優先緊急狀況。
- C腳趾觸摸起來冰冷但顏色呈粉紅色
腳趾發涼可能與環境有關，只要顏色紅潤、微血管充填時間正常，通常代表周邊血循尚未受阻，可密切觀察。
- D石膏上有少量漿液血性滲出液
石膏上出現少量漿液血性滲液在術後是可預期的，護理師應圈記範圍與時間，觀察是否快速擴大即可。
美國 NCLEX 強調 6P（Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia），其中疼痛是首要。台灣臨床有時過度依賴脈搏（Pulselessness），但脈搏消失通常已是末期，需強調疼痛評估的重要性。
English explanation
Core concept: Early identification of compartment syndrome. This is the most dangerous complication after fracture immobilization in a cast. Why the correct answer is right: Pain that worsens despite analgesics, or pain disproportionate to the injury, is the earliest sign of compartment syndrome (pain out of proportion). Why the other options are wrong: B is common discomfort; C is borderline (cool toes but pink color indicating adequate circulation, requiring continued observation); D is typically expected if it is a small amount of postoperative serosanguinous drainage. Clinical reasoning: The nurse must be able to anticipate critical complications and detect abnormalities through changes in the character of pain before neurovascular damage becomes irreversible (such as absent pulse) and intervene immediately.
最近修訂：2026-10-05