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降低風險 · HARD · SATA

護理師評估一位病人是否出現手術部位感染。下列哪些發現應回報外科醫師?(選所有適合的)

A nurse is assessing a client for potential surgical site infection. Which assessment findings should the nurse report to the surgeon? (Select all that apply.)

  • APurulent drainage from the incision site✓ 正解
    切口處有膿性分泌物
  • BSerosanguinous drainage on the dressing
    敷料上有漿液血性滲出物
  • CErythema extending beyond the incision edges✓ 正解
    紅斑擴散至切口邊緣以外
  • DIncreased warmth around the surgical area✓ 正解
    手術區域周圍溫度升高
  • EFever greater than 38.5 degrees Celsius✓ 正解
    體溫高於 38.5 攝氏度
Explanation · 中文詳解

手術部位感染(Surgical Site Infection, SSI)的評估需結合局部與全身性反應。紅、腫、熱、痛及膿性分泌物是典型發炎與感染徵兆。若傷口出現膿性分泌物或紅斑擴散超過傷口邊緣,顯示感染已在擴散。全身性反應如發燒(>38.5°C)則提示感染可能已轉為全身性,必須迅速回報醫師進行傷口培養或調整抗生素治療。

Assessment of a surgical site infection (SSI) requires evaluation of both local and systemic responses. Redness, swelling, warmth, pain, and purulent drainage are typical signs of inflammation and infection. Purulent drainage or erythema extending beyond the wound edges indicates that the infection is spreading. Systemic responses such as fever (>38.5 degrees C) suggest the infection may have become systemic and must be reported promptly so the provider can obtain wound cultures or adjust antibiotic therapy.

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