— 降低風險 · EASY · MCQ —
護理師照顧一位腹部手術後的病人。下列哪項發現暗示傷口裂開的可能？
A nurse is caring for a client who is post-operative following an abdominal surgery. Which finding suggests a potential wound dehiscence?
- AThe client reports a sudden 'popping' sensation at the incision site✓ 正解病人報告切口處有突然的「彈開」感
- BSmall amount of serosanguineous drainage on the dressing敷料上有少量血清血性滲出物
- CThe incision site is warm to the touch切口部位觸摸時發熱
- DClient reports a pain level of 4 out of 10病人報告疼痛程度為10分中的4分
— Explanation · 中文詳解 —
傷口裂開（Dehiscence）通常發生在劇烈咳嗽或腹部壓力增加後，病人常描述感覺到「砰」一聲，隨後傷口處有滲液或傷口邊緣分開。這是外科手術後的緊急警訊。其他選項如微量血清液滲出或輕微疼痛多為術後預期內的臨床過程。
A sudden 'popping' sensation at the incision site is a classic indicator of fascial separation and potential wound dehiscence. This symptom requires immediate assessment, whereas minor drainage or expected pain levels are not specific signs of this complication.
✦ 台美臨床差異
無明顯差異，兩地均強調傷口衛教中若發生此類現象需立即臥床並通知醫師。