護理師應採取哪項行動來預防右臂新打石膏病人的併發症?
Which action should the nurse take to prevent complications for a client with a new cast on the right arm?
- AAssess fingers for color, temperature, and sensation✓ 正解評估手指的顏色、溫度和感覺
- BKeep the arm below the level of the heart將手臂保持在低於心臟水平的位置
- CUse a pen to scratch the skin under the cast if it itches若石膏下皮膚搔癢,用筆刮擦皮膚
- DApply heat to the cast to speed up drying對石膏施加熱量以加速乾燥
對於右臂新打石膏的病人,護理師最重要的職責是預防嚴重的併發症,特別是腔室症候群 (compartment syndrome)。腔室症候群是一種骨折或創傷後可能發生的嚴重狀況,由於石膏或腫脹導致肢體腔室內壓力升高,壓迫血管和神經,若不及時處理可能導致永久性的神經血管損傷、肢體功能喪失甚至截肢。因此,持續且頻繁地評估石膏遠端肢體的神經血管功能是護理的優先事項。護理師應評估遠端肢體的顏色 (color)、溫度 (temperature)、感覺 (sensation)、運動 (movement) 和脈搏 (pulses),這些是所謂的「5 Ps」,以早期發現任何缺血或神經受損的跡象,確保肢體的血液循環和神經功能正常。
Neurovascular assessments are critical to detect early signs of compartment syndrome or circulation impairment. Checking color, temperature, sensation, and pulses ensures that swelling or a tight cast is not compromising blood flow or nerve function in the affected limb.
台美兩地的臨床實踐對於石膏照護及腔室症候群的監測原則是完全一致的,神經血管評估(5 Ps:疼痛、蒼白、麻痺、感覺異常、無脈搏)是護理常規,且都強調早期發現和介入的重要性。病人衛教也同樣強調避免自行搔抓和保持石膏乾燥。