— 生理適應 · EASY · MCQ —
病人術後恢復期，下列哪項評估發現暗示傷口裂開的潛在併發症？
A client is recovering from abdominal surgery. Which assessment finding indicates a potential complication of wound dehiscence?
- AThe client complains of intense itching around the incision客戶抱怨切口周圍有強烈搔癢感
- BPurulent drainage from the suture site縫合處有膿性分泌物
- CSerosanguineous drainage increasing on the dressing✓ 正解敷料上的漿液血性分泌物增加
- DAbsence of bowel sounds in the abdomen腹部無腸鳴音
— Explanation · 中文詳解 —
傷口裂開（Dehiscence）的典型徵兆包括切口處突然出現大量的漿液性血性分泌物。這是因為深層組織結構受損導致內部液體流出。化膿通常指向感染；腸蠕動音消失則與腸阻塞相關；癢感則可能是癒合過程或對縫線過敏，均非急性裂開的直接徵象。
A classic sign of wound dehiscence is the sudden appearance of large amounts of serosanguineous drainage at the incision, caused by separation of the deeper tissue layers, allowing internal fluid to escape. Purulent drainage typically indicates infection; absent bowel sounds relate to ileus; and itching may reflect normal healing or suture allergy and is not a direct sign of acute dehiscence.
✦ 台美臨床差異
兩地針對術後傷口照護的標準流程相似，台灣護理師對於術後傷口觀察紀錄較為詳盡，針對滲出液之型態描述要求嚴格。