— 生理適應 · MEDIUM · MCQ —
一位病人甲狀腺切除術後返回病房，哪項評估結果需要立即處置？
A client is returned to the nursing unit after a thyroidectomy. Which assessment finding requires immediate intervention?
- AHoarseness when speaking說話時聲音沙啞
- BStridor and noisy respirations✓ 正解喘鳴及呼吸雜音
- CMild discomfort at the incision site切口處輕微不適
- DPresence of a surgical drain with minimal serosanguineous drainage有外科引流管且血清血性引流液量少
— Explanation · 中文詳解 —
甲狀腺切除術後，喘鳴聲（Stridor）是喉頭水腫或血腫壓迫氣道的警訊，隨時可能導致呼吸道完全阻塞。護理師必須立即呼叫緊急醫療團隊，並準備氣管插管工具。相較之下，聲音嘶啞可能是喉返神經受損，傷口不適則為預期內反應，皆非立即致命。
After thyroidectomy, stridor is a warning sign of laryngeal edema or hematoma compressing the airway, which may at any time progress to complete airway obstruction. The nurse must immediately summon the emergency medical team and prepare intubation equipment. By comparison, hoarseness may indicate recurrent laryngeal nerve injury, and incisional discomfort is an expected response; neither is immediately life-threatening.
✦ 台美臨床差異
美國常見由 Rapid Response Team 處理呼吸道危機，台灣則通常由值班醫師或麻醉科醫師立即緊急處理。