一位病人因壓砸傷導致右小腿發生腔室症候群 (Compartment Syndrome)。護理師應識別出下列哪項評估發現是此併發症的「早期」徵兆？
A client is diagnosed with compartment syndrome in the right lower leg following a crush injury. Which assessment finding should the nurse identify as an early sign of this complication?
- AParalysis of the right foot右腳麻痺
- BParesthesia and intense pain unrelieved by opioids感覺異常及嗎啡無法緩解的劇痛正確答案
- CCool, cyanotic skin of the right toes右腳趾皮膚冰冷、發紺
- DAbsence of a palpable pedal pulse足背脈搏消失
- B感覺異常及嗎啡無法緩解的劇痛
腔室症候群是骨科急症，其臨床表現常被稱為 6Ps（Pain, Pressure, Paresthesia, Pallor, Paralysis, Pulselessness）。區分「早期」與「晚期」徵兆是考點關鍵。早期徵兆主要是感覺異常（Paresthesia，如刺痛或麻木）以及「與受傷程度不成比例的劇烈疼痛」，且這種疼痛對鴉片類止痛藥反應不佳。神經組織對缺血最敏感，因此感覺改變最先出現。而選項 D（脈搏消失）、A（癱瘓）、C（發紺）都屬於晚期徵兆，代表組織已經發生不可逆的壞死。護理師必須在「早期」階段就警覺並通知醫師進行筋膜切開術（Fasciotomy），否則將導致肢體永久性功能喪失。這體現了護理師在風險降低中「及早偵測」的重要性。
- A右腳麻痺
癱瘓代表運動神經已受損且肌肉發生壞死，屬於不可逆階段的表現，不再是早期警訊。
- B · 正確答案感覺異常及嗎啡無法緩解的劇痛
對止痛藥無效的劇痛和感覺異常是神經受壓迫的最早訊號，護理師應在此階段立即通報以安排急診手術。
- C右腳趾皮膚冰冷、發紺
皮膚冰冷與發紺反映了血液循環停止後的末梢變化，出現這些徵兆時通常已錯過最佳挽救時機。
- D足背脈搏消失
脈搏消失是極晚期的表現，代表腔室壓力已超過動脈壓，此時組織往往已經發生嚴重缺血壞死。
美國護理教育極度強調 6Ps 的順序性與早期介入（Fasciotomy）；台灣臨床上護理師雖然也懂 6Ps，但在面對劇痛病人時，有時會傾向先聯繫醫師給予更多止痛藥，而非第一時間懷疑腔室症候群。
English explanation
Option B is correct because paresthesia, such as tingling or numbness, and intense pain out of proportion to the injury that responds poorly to opioids are early findings of compartment syndrome. This orthopedic emergency is associated with pain, pressure, paresthesia, pallor, paralysis, and pulselessness. Neural tissue is especially sensitive to ischemia, so sensory changes appear first. Option A is incorrect because paralysis of the foot is a late sign. Option C is incorrect because cyanosis is also a late sign. Option D is incorrect because an absent pedal pulse occurs late. These late findings indicate that irreversible tissue necrosis has already developed. The nurse must recognize the early stage and notify the physician so that a fasciotomy can be performed; otherwise, permanent loss of limb function may result. This emphasizes the nurse's role in early detection and risk reduction.