— 降低風險 · HARD · SATA —
護理師評估一位石膏固定的病人，哪些發現需立即通知醫師？（選所有適合的）
A nurse is assessing a client with a casted leg. Which findings should the nurse report to the provider immediately? (Select all that apply.)
- ACapillary refill time of 5 seconds✓ 正解毛細血管再充盈時間為 5 秒
- BPain relieved by elevation and ice疼痛經抬高和冰敷後緩解
- CParesthesia in the affected toes✓ 正解患側腳趾感覺異常
- DInability to move the toes✓ 正解無法活動腳趾
- ESkin cool to the touch distal to the cast✓ 正解石膏遠端皮膚觸感冰冷
— Explanation · 中文詳解 —
石膏固定後發生腔室症候群（Compartment Syndrome）的風險極高。6P 徵象包含疼痛（Pain）、感覺異常（Paresthesia）、癱瘓（Paralysis）、蒼白（Pallor）、搏動消失（Pulselessness）及毛細血管充盈時間延長（Poikilothermia/Refill delay）。選項 A、C、D、E 均為神經血管受損的跡象，需立即處理。B 項為預期中的緩解反應。
Findings such as delayed capillary refill, paresthesia, inability to move toes, and cool skin distal to the cast are signs of neurovascular compromise, potentially indicating compartment syndrome. These symptoms require immediate reporting to the provider, whereas pain relief with elevation is an expected response to musculoskeletal injury.
✦ 台美臨床差異
在台灣，護理師若發現 6P 徵象會立即通知醫師並準備石膏切割（bivalve）；美國護理流程亦同，強調及早介入以避免永久性損傷。