— 生理適應 · HARD · SATA —
護理師照顧一位新造口（colostomy）的病人，下列哪些發現需立即通報外科醫師？（選所有適合的）
A nurse is caring for a client with a new colostomy. Which findings should be reported to the surgeon immediately? (Select all that apply.)
- AStoma appears dark purple or black✓ 正解造口呈現暗紫色或黑色
- BStoma is bright red and moist造口呈現鮮紅色且潮濕
- CNo drainage from the stoma after 24 hours✓ 正解造口在24小時後無排泄物
- DSkin around the stoma is excoriated造口周圍皮膚有擦傷
- EStoma bleeding slightly when cleaned清潔時造口有少量出血
— Explanation · 中文詳解 —
造口術後觀察重點為血液循環狀況。正常的造口應為紅潤、濕潤，清潔時有少量出血是正常的（微血管豐富）。若造口呈現深紫色或黑色，代表發生缺血壞死（紅旗）；若術後一段時間完全無排泄物，可能發生腸阻塞或造口回縮。
A stoma appearing dark purple or black indicates ischemia and necrosis, requiring immediate surgical intervention. Additionally, no drainage after 24 hours may signal an obstruction or retraction. In contrast, a bright red, moist stoma with slight bleeding during cleaning is normal, and skin excoriation, while needing care, is not an emergency.
✦ 台美臨床差異
美國造口護理師（WOCN）角色明確，護理介入較早；台灣多由專科護理師或病房護理師共同評估。