— 降低風險 · MEDIUM · MCQ —
護理師評估一位全髖關節置換術後 24 小時的病人，下列哪項發現需優先回報給醫療團隊？
A nurse is assessing a client who is 24 hours post-operative from a total hip arthroplasty. Which finding is the highest priority to report to the provider?
- APain level of 5 on a scale of 0 to 10疼痛程度為 0 至 10 分中的 5 分
- BSerosanguineous drainage on the dressing敷料上有漿液血性滲出物
- CDecreased bowel sounds in all four quadrants四個象限的腸鳴音減弱
- DCalf pain and tenderness in the affected leg✓ 正解患肢小腿疼痛及壓痛
— Explanation · 中文詳解 —
術後病人發生深部靜脈栓塞（DVT）的風險極高。小腿疼痛、觸痛及腫脹是 DVT 的經典徵象。若血栓脫落可能導致致命的肺栓塞。相較於正常的引流物、術後疼痛或術後麻醉藥引起的腸蠕動減弱，DVT 的風險更具危險性，需優先執行評估與干預。
Calf pain and tenderness in a post-operative hip arthroplasty client are classic signs of deep vein thrombosis (DVT). DVT is a serious complication that can lead to a potentially fatal pulmonary embolism if a clot dislodges. This finding takes priority over expected post-operative symptoms such as moderate pain, serosanguineous drainage, or decreased bowel sounds.
✦ 台美臨床差異
美台臨床皆重視 DVT 預防，但美國護理師依 protocol 啟動評估流程的速度通常較快。