— 生理適應 · HARD · SATA —
一位剛造口手術的病人。護理師發現哪些情況應立即通知醫療團隊？（選所有適合的）
A nurse is caring for a client with a new colostomy. Which findings should the nurse report to the healthcare provider immediately? (Select all that apply.)
- AStoma is dusky and dark purple in appearance✓ 正解造口呈現蒼白且深紫色
- BSlight bleeding on the edges of the stoma造口邊緣有輕微出血
- CAbsence of stool output for 24 hours✓ 正解24小時內無糞便排出
- DStoma is beefy red and swollen造口呈現牛肉紅色且腫脹
- ESevere skin excoriation around the stoma site造口周圍皮膚嚴重浸潤破損
— Explanation · 中文詳解 —
造口處色澤若轉為暗紫色或黑色代表缺血壞死，是需立即手術干預的緊急狀況。術後 24 小時內若未排氣排便，可能存在阻塞或腸扭轉。紅潤腫脹屬正常術後反應；邊緣少許出血係黏膜脆弱所致；皮膚紅腫潰爛雖需處理但非立即危及生命。
A dusky or dark purple stoma indicates ischemia and necrosis, which is a surgical emergency requiring immediate intervention. Additionally, an absence of stool output for 24 hours post-operatively may suggest an intestinal obstruction. While minor bleeding and beefy red swelling are normal findings, they do not require urgent reporting compared to signs of compromised circulation or blockage.
✦ 台美臨床差異
美國造口治療師（WOCN）資源充足，護理師常會諮詢其意見；台灣多由病房護理師自行處理皮膚照護。