— 基本照護與舒適 · MEDIUM · MCQ —
對於一位新造口病人,下列哪項是預期內的發現?
Which of the following is an expected finding for a client with a new stoma?
- AStoma is black and dry造口呈黑色且乾燥
- BStoma is pale and gray造口蒼白且灰暗
- CStoma has no sensation造口無知覺
- DStoma is red, moist, and beefy✓ 正解造口紅潤、濕潤且呈牛肉色
— Explanation · 中文詳解 —
健康的造口應呈現紅潤、濕潤且有光澤(像牛肉質地)。黑色表示壞死,灰白色表示貧血或缺血,這兩者皆為異常且需立即處理。造口本身沒有神經分布(無痛覺),但這不是「預期內的發現」來定義健康,選項 D 才最能代表其健康狀態。
A healthy stoma appears red, moist, and beefy, which indicates adequate blood supply and proper healing. Deviations such as blackness or pallor suggest necrosis or ischemia and require urgent medical attention.
✦ 台美臨床差異
美台護理對於造口健康評估標準一致,皆將紅潤濕潤視為健康指標。