— 降低風險 · HARD · MCQ —
病人踝關節受傷，護理師評估神經血管狀況。下列哪項發現暗示可能存在神經血管受損？
A client presents with an ankle injury. The nurse assesses neurovascular status. Which finding indicates potential neurovascular compromise?
- APain that is disproportionate to the injury✓ 正解與傷害程度不成比例疼痛
- BPalpable pulse in the extremity肢體可觸摸到脈搏
- CEdema that is slightly pitting輕微凹陷性水腫
- DCapillary refill of 2 seconds毛細血管充盈時間為 2 秒
— Explanation · 中文詳解 —
神經血管受損的經典早期徵象是「痛得與傷勢不符」（Pain out of proportion），這常暗示發生腔室症候群（Compartment Syndrome）的警訊。正常毛細血管充盈時間應小於 3 秒，脈搏可觸及代表灌流尚存，輕微水腫為受傷後的正常發炎反應。
Pain disproportionate to the injury is a critical early sign of neurovascular compromise, often indicating compartment syndrome. While palpable pulses and capillary refill under three seconds suggest adequate perfusion, excessive pain signals rising pressure within the fascial compartments. Immediate assessment and intervention are required to prevent tissue necrosis.
✦ 台美臨床差異
美國護理師常執行系統性的 6P 評估；台灣護理師亦會評估但對於 6P 的整體概念整合較依賴病歷紀錄。