護理師評估疑似深部靜脈栓塞 (DVT) 的病患。下列哪些發現符合此診斷?(選所有適合的)
A nurse is performing a physical assessment on a client with suspected deep vein thrombosis (DVT). Which assessment findings are consistent with DVT? (Select all that apply.)
- AUnilateral leg swelling✓ 正解單側腿部水腫
- BLocalized warmth in the calf✓ 正解小腿局部發熱
- CDiminished pedal pulses足背脈搏減弱
- DTenderness along the venous distribution✓ 正解靜脈走行區域壓痛
- EPale, cool, and pulseless extremity肢體蒼白、冰冷且無脈搏
深部靜脈栓塞(DVT)的典型臨床表現源於靜脈血液回流受阻與局部發炎反應。單側肢體水腫(unilateral edema)是因為栓子阻塞靜脈導致血液淤積,局部發熱(warmth)與沿靜脈壓痛(tenderness)則是血管壁發炎的徵象。動脈血流不足才會出現蒼白、發冷與脈搏減弱,這些是用來區分血管阻塞性質的關鍵。護理師應避免按摩患肢,以防栓子脫落引發肺栓塞(PE)。
The typical clinical presentation of deep vein thrombosis (DVT) arises from obstructed venous return and a localized inflammatory response. Unilateral limb edema results from the thrombus obstructing the vein and causing blood stasis, while local warmth and tenderness along the venous distribution are signs of inflammation of the vessel wall. Pallor, coolness, and diminished pulses indicate insufficient arterial blood flow and are key findings used to distinguish the nature of vascular obstruction. The nurse should avoid massaging the affected limb to prevent dislodgement of the thrombus and subsequent pulmonary embolism (PE).