— 降低風險 · MEDIUM · MCQ —
護理師照顧一位小腿剛打上石膏的病人，哪項評估最為優先？
A nurse is caring for a client with a new cast on the lower leg. What is the priority assessment?
- AItchiness under the cast石膏下的搔癢感
- BWeight of the cast石膏的重量
- CDryness of the cast石膏的乾燥程度
- DSkin color of the toes✓ 正解腳趾的皮膚顏色
— Explanation · 中文詳解 —
石膏可能會導致組織腫脹，若過緊會發生腔室症候群（Compartment Syndrome），導致肢體缺血壞死。評估遠端肢體（如腳趾）的顏色、溫度、感覺、運動能力（Neurovascular check）是護理師最優先的任務。
Assessing skin color, temperature, sensation, and movement in the toes is the priority to detect neurovascular compromise or compartment syndrome early. Casts can restrict circulation and cause tissue ischemia if swelling occurs, making frequent neurovascular checks essential. While itching and dryness are common concerns, they do not pose the same immediate threat to limb viability as vascular obstruction.
✦ 台美臨床差異
台美臨床對於石膏後的神經血管監測（6P’s）教學與實作完全一致。