— 生理適應 · EASY · MCQ —
護理師照顧一位新造口病人，下列哪項發現需要立即介入？
A nurse is caring for a client with a new colostomy. Which assessment finding requires immediate intervention?
- AStoma size is smaller than initial assessment造口大小小於初始評估值
- BStoma is dark purple or black✓ 正解造口呈深紫色或黑色
- CStoma is red and moist造口呈紅色且濕潤
- DSmall amount of bleeding during cleaning清潔時有少量出血
— Explanation · 中文詳解 —
造口應呈現鮮紅且濕潤，代表血液灌流充足。深紫色、黑色或蒼白代表缺血或壞死，屬於急診狀況，因嚴重缺氧可能導致腸管穿孔或壞死。輕微出血屬正常現象，隨時間會減少；造口術後因腫脹消退，尺寸縮小是術後恢復的自然過程，無需擔憂。
Enoxaparin should be administered into the anterolateral abdominal wall to ensure consistent absorption. The air bubble in the prefilled syringe is intentional to deliver the full dose, and the site should not be massaged to prevent hematoma formation. Aspiration is unnecessary for subcutaneous injections.
✦ 台美臨床差異
台美皆依據造口顏色判定危急程度，但美國護理師常與 WOCN 合作，台灣多由專科護理師協助評估。