— 生理適應 · EASY · SATA —
護理師照顧一位新造人工肛門（結腸造口）的病人，哪些發現應紀錄為正常？（選所有適合的）
A nurse is caring for a client with a new colostomy. Which findings should the nurse document as normal? (Select all that apply.)
- AStoma is red and moist✓ 正解造口呈紅色且濕潤
- BSmall amount of bleeding during cleaning✓ 正解清潔時少量出血
- CStoma is pale and dry造口蒼白且乾燥
- DStoma protrudes slightly from the skin✓ 正解造口略突出於皮膚表面
- EPurple or black stoma color造口呈紫色或黑色
— Explanation · 中文詳解 —
正常的造口外觀應為鮮紅色、濕潤且有光澤。由於造口黏膜富含血管，清潔時輕微滲血是正常現象。造口會略微凸出皮膚表面，以便排泄物順利進入袋內。紫色或黑色代表組織壞死，蒼白則可能為貧血或血流不足，皆為異常徵象。
A healthy stoma appears bright red and moist due to its rich vascular supply, and slight protrusion from the skin helps facilitate drainage into the ostomy bag. Minor bleeding during cleaning is normal because the mucosal tissue is highly vascular and fragile. Pale, purple, or black discoloration indicates compromised perfusion, ischemia, or necrosis, which are abnormal findings requiring immediate medical attention.
✦ 台美臨床差異
造口護理在兩地皆由護理師主導，但台灣有專門的造口治療師（WOCN）制度，協助特殊個案處理。