— 生理適應 · MEDIUM · MCQ —
一位腿部剛打石膏的病人，雖給予止痛藥但疼痛加劇。護理師應評估什麼？
A client with a new cast on the lower leg reports increasing pain despite analgesics. What should the nurse assess for?
- ANormal inflammatory response正常的發炎反應
- BDVT symptoms深部靜脈血栓形成（DVT）症狀
- CSkin irritation under the cast石膏下的皮膚刺激
- DSigns of Compartment Syndrome✓ 正解腔室症候群的徵象
— Explanation · 中文詳解 —
石膏下疼痛加劇且對止痛藥反應不佳，是「腔室症候群（Compartment Syndrome）」的紅旗徵兆。需評估 5P（Pain, Pallor, Pulselessness, Paresthesia, Paralysis）。這是緊急狀況，若未即時處置恐導致永久性神經肌肉損傷。
Increasing pain that is unrelieved by analgesics in a client with a new cast is a primary early sign of compartment syndrome, a medical emergency. The nurse must immediately assess for other signs of compromised circulation and nerve function, such as pallor, pulselessness, paresthesia, and paralysis, to prevent permanent tissue damage.
✦ 台美臨床差異
美國護理指引對 Neurovascular check 極為重視，護理師需每小時記錄；台灣臨床亦然，但教育訓練中特別強調石膏切開的緊急應變。