護理師正在評估一位全膝關節置換術後病人的潛在併發症。下列哪些徵象應列為評估重點?(選所有適合的)
A nurse is evaluating potential complications for a client who underwent total knee replacement surgery. Which signs should the nurse prioritize in the assessment? (Select all that apply.)
- APain that increases despite medication administration✓ 正解即使給藥後疼痛仍加劇
- BCalf tenderness and swelling✓ 正解小腿壓痛與腫脹
- CDecreased sensation in the affected limb✓ 正解患肢感覺減退
- DClear, yellow drainage on the surgical dressing手術敷料上有清澈、黃色的引流液
- ECapillary refill time of 2 seconds微血管回充時間為 2 秒
全膝關節置換術後,護理師必須警覺神經血管受損與深部靜脈栓塞(DVT)等併發症。評估重點在於「6P」指標(Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia)。若術後疼痛不減反增,或出現栓塞徵象,需立即通報醫師。良好的術後護理應包含循環評估與疼痛控制的平衡。
After total knee replacement, nurses must prioritize assessing for complications such as compartment syndrome, deep vein thrombosis (DVT), and nerve damage. Increasing pain unrelieved by medication, calf tenderness, and decreased sensation are key indicators of these serious conditions. In contrast, clear serous drainage and normal capillary refill times are expected findings in the postoperative period.