— 降低風險 · MEDIUM · SATA —
護理師照護一位下肢打石膏的病人，應執行哪些評估以監測神經血管受損情況？（選所有適合的）
A nurse is caring for a client with a new cast on the lower leg. Which assessments should the nurse perform to monitor for neurovascular compromise? (Select all that apply.)
- ACapillary refill time✓ 正解毛細血管回充時間
- BPresence of distal pulses✓ 正解遠端脈搏的存在與否
- CAbility to move the toes✓ 正解腳趾的活動能力
- DSkin temperature of the extremity✓ 正解肢體的皮膚溫度
- EAssessment of skin color✓ 正解皮膚顏色的評估
— Explanation · 中文詳解 —
石膏過緊會造成腔室症候群，評估神經血管狀況需觀察 5P 徵象：脈搏（Pulses）、蒼白（Pallor）、感覺異常（Paresthesia）、癱瘓（Paralysis）、疼痛（Pain）。除了這些，還要檢查毛細血管回充時間與皮膚溫度。
The nurse should assess capillary refill, distal pulses, toe movement, skin temperature, and skin color to monitor for neurovascular compromise. These assessments correspond to the 5 Ps of compartment syndrome—pulselessness, pallor, paresthesia, paralysis, and pain—and help detect arterial obstruction or nerve compression caused by a tight cast.
✦ 台美臨床差異
兩地護理師對神經血管評估標準一致，但台灣臨床多使用「石膏評估表」定期記錄，美國則強調護理師的自主判斷。