— 降低風險 · MEDIUM · SATA —
護理師照護一位小腿新打石膏的病人。為偵測神經血管受損，應執行哪些評估？（選所有適合的）
A nurse is caring for a client with a new cast on their lower leg. Which assessments should the nurse perform to detect neurovascular impairment? (Select all that apply.)
- ACheck for capillary refill time✓ 正解檢查毛細血管再充盈時間
- BAssess the temperature of the toes✓ 正解評估腳趾的溫度
- CAsk about the presence of tingling or numbness✓ 正解詢問是否有刺痛或麻木感
- DObserve the color of the skin distal to the cast✓ 正解觀察石膏遠端皮膚的顏色
- EAssess the ability to move the toes✓ 正解評估腳趾的活動能力
— Explanation · 中文詳解 —
石膏過緊容易引發腔室症候群（Compartment Syndrome），評估神經血管狀況應包含 6P 原則中的檢查：脈搏、蒼白（顏色）、感覺異常（刺痛）、麻痺（活動度）、溫度與微血管回充時間。若出現異常應立即通知醫師，不可延誤。
Assessments for neurovascular impairment include checking capillary refill, toe temperature, skin color, sensation, and motor function. These evaluations align with the 6Ps of compartment syndrome, such as pallor, paresthesia, and paralysis, which indicate potential circulation or nerve issues. Early detection of these signs allows for prompt intervention to prevent permanent damage.
✦ 台美臨床差異
台美皆強調 6P 評估，但在病歷記錄上，台灣常習慣使用「P-P-P」簡寫，美國則更強調護理師的主動干預與 Escalation 流程。