— 生理適應 · MEDIUM · MCQ —
護理師照護一位下肢打石膏的病人，偵測腔室症候群的最優先評估為何？
A nurse is caring for a client with a new cast on the lower leg. What is the priority assessment to detect compartment syndrome?
- APresence of pedal pulses足背脈搏的存在
- BSkin temperature of the toes腳趾皮膚溫度
- CCapillary refill time毛細血管再充盈時間
- DPain intensity and quality✓ 正解疼痛強度和性質
— Explanation · 中文詳解 —
腔室症候群（Compartment syndrome）最早期且最敏感的徵象是「超出損傷程度的疼痛」，且對常規止痛藥反應不佳。脈搏消失是極晚期的徵兆，一旦發生往往已造成不可逆的壞死。護理師必須在疼痛劇烈階段就高度警覺，觀察是否有疼痛加劇、被動活動疼痛（Passive stretch pain）等表徵，以預防嚴重後果。
Pain out of proportion to the injury is the earliest and most sensitive sign of compartment syndrome, often unrelieved by analgesics. While pulselessness is a critical finding, it is a late sign indicating irreversible damage may have already occurred.