— 降低風險 · EASY · MCQ —
護理師照護一位全髖關節置換術後的病人。下列哪項措施對於降低神經血管損傷風險最為優先？
A nurse is caring for a client who is post-operative following a total hip arthroplasty. Which intervention is the priority to reduce the risk of neurovascular compromise?
- AAdminister prophylactic anticoagulants as ordered依指示給予預防性抗凝血劑
- BEncourage the client to perform deep breathing exercises鼓勵病人進行深呼吸運動
- CAssess pedal pulses, capillary refill, and sensation every 2 hours✓ 正解每 2 小時評估足背脈搏、微血管回充及感覺
- DEnsure the use of an abduction pillow between the legs確保雙腿之間使用外展枕
— Explanation · 中文詳解 —
神經血管評估是術後評估的核心，為了偵測早期的 compartment syndrome 或術後神經損傷，必須優先針對受損肢體進行循環及感覺評估。雖然其他選項也是護理常規，但維持肢體血流與神經功能是維護個案肢體完整性的最核心指標。
Assessing pedal pulses, capillary refill, and sensation every two hours is the priority intervention to detect early signs of neurovascular compromise, such as ischemia or nerve injury, following total hip arthroplasty. While anticoagulants and abduction pillows address other risks like DVT and dislocation, direct neurovascular monitoring is critical for preserving limb integrity.
✦ 台美臨床差異
美國護理師在術後照護常更依賴神經血管評估表進行記錄；台灣則常合併其他肢體照護指標執行。