— 降低風險 · HARD · SATA —
護理師照護一位下肢剛上石膏的病人，下列哪些評估結果顯示有腔室症候群的風險？（選所有適合的）
A nurse is caring for a client with a new cast on the lower leg. Which assessments indicate potential compartment syndrome? (Select all that apply.)
- APain that is unrelieved by medication✓ 正解服藥後疼痛仍未緩解
- BCapillary refill of 2 seconds in the toes腳趾毛細血管再充盈時間為 2 秒
- CParesthesia or numbness in the affected foot✓ 正解患足出現麻刺感或麻木
- DPalpable pulses that are bounding觸摸到強而有力的脈搏
- EPain that increases with passive stretch✓ 正解被動伸展時疼痛加劇
— Explanation · 中文詳解 —
腔室症候群的經典臨床表徵為 6P：疼痛（Pain，特別是服用止痛藥無效或被動伸展時更痛）、蒼白（Pallor）、感覺異常（Paresthesia）、脈搏減弱（Pulselessness）、麻痺（Paralysis）與壓力感（Pressure）。選項 B 的回充正常、D 的強脈搏均非症候群表現。
Compartment syndrome is indicated by pain that is unrelieved by medication and worsens with passive stretching of the affected muscles. Paresthesia or numbness suggests nerve ischemia, which is another early sign of increased compartment pressure. These findings require immediate intervention to prevent permanent tissue damage.
✦ 台美臨床差異
美國護理師常需負責術後第一時間神經血管評估，台灣則依醫師查房與護理師交班紀錄輔助判斷。