— 降低風險 · EASY · MCQ —
護理師照護一位手術後病人，哪項發現應被視為傷口感染的早期跡象？
A nurse is caring for a postoperative client with an incisional wound. Which finding should the nurse recognize as an early sign of infection?
- AAbsence of pain缺乏疼痛
- BPresence of a dry scab存在乾燥的結痂
- CSerosanguineous drainage漿液血性引流液
- DLocal redness and warmth✓ 正解局部紅腫和發熱
— Explanation · 中文詳解 —
傷口感染的局部徵象（紅、腫、熱、痛）通常在發燒等全身反應前出現。局部發紅與發熱（Redness and warmth）是發炎反應指標。漿液血性分泌物是術後早期正常癒合過程；痂皮是正常保護構造；無痛感無法作為感染指標。
The local signs of wound infection (redness, swelling, warmth, and pain) typically appear before systemic responses such as fever. Localized redness and warmth are indicators of an inflammatory response. Serosanguineous drainage is a normal part of early postoperative healing; a scab is a normal protective structure; absence of pain cannot serve as an indicator of infection.
✦ 台美臨床差異
美國護理師常利用傷口癒合評估表（如PUSH tool）記錄，台灣臨床對傷口感染之判斷多依賴資深護理師經驗及醫師診視。