— 降低風險 · MEDIUM · SATA —
護理師評估一位疑似深層靜脈栓塞（DVT）的病人，下列哪些症狀是評估重點？（選所有適合的）
A nurse is assessing a client with a suspected DVT. Which manifestations should the nurse look for? (Select all that apply.)
- AUnilateral calf swelling✓ 正解單側小腿腫脹
- BWarmth and redness of the affected extremity✓ 正解患肢發熱和紅斑
- CSudden onset of dyspnea突發性呼吸困難
- DCoolness of the extremity患肢冰冷
- ETenderness along the venous system✓ 正解沿靜脈路徑有壓痛
— Explanation · 中文詳解 —
深層靜脈栓塞（DVT）常見表徵包括單側小腿腫脹、局部發紅、發熱及沿著靜脈走向的壓痛。選項 C（呼吸困難）通常是 DVT 脫落引發肺栓塞（PE）的表現，並非 DVT 本身的局部症狀。選項 D（肢體冰冷）多見於動脈阻塞，與靜脈問題不同。
Classic manifestations of deep vein thrombosis (DVT) include unilateral calf swelling, warmth, redness, and tenderness along the affected vein due to inflammation and venous obstruction. Sudden dyspnea suggests a pulmonary embolism, a complication of DVT, rather than the DVT itself, while coolness of the extremity is indicative of arterial insufficiency.
✦ 台美臨床差異
美台皆依賴 D-dimer 與超音波診斷，但在護理評估上，台灣對於懷孕期或臥床病人的觀察更為積極。