— 生理適應 · HARD · MCQ —
一位開顱術後 24 小時的病人，何項發現最令人擔憂？
Which assessment finding is most concerning for a client 24 hours post-craniotomy?
- AClear fluid drainage on the dressing敷料上有清澈液體引流
- BLow-grade temperature低燒
- CIncreased pupil size on one side✓ 正解單側瞳孔擴大
- DPeriorbital edema眼周水腫
— Explanation · 中文詳解 —
開顱術後單側瞳孔變大，極可能是腦疝脫或顱內血腫造成的腦幹壓迫，這是威脅生命的緊急徵象。眼周水腫常見，輕微發燒術後偶見，傷口有少量引流物需確認是否為腦脊髓液（CSF），但單側瞳孔不等大是腦部損傷最危險的信號。
Increased pupil size on one side 24 hours post-craniotomy is the most concerning finding as it may indicate brain herniation or increased intracranial pressure compressing the brainstem. While mild fever or periorbital edema can be expected post-operatively, unilateral pupillary changes represent a critical neurological emergency requiring immediate intervention.
✦ 台美臨床差異
台美神經外科術後對意識狀態與瞳孔的監測準則極為嚴謹，皆列為最高優先護理。