— 降低風險 · MEDIUM · MCQ —
護理師照護一位小腿上石膏的病人，哪項評估發現需立即通知醫師？
A nurse is planning care for a client with a fresh cast on their lower leg. Which assessment finding requires immediate notification of the provider?
- AAbility to wiggle the toes能夠活動腳趾
- BMinimal edema of the toes腳趾輕微水腫
- CSkin temperature cooler than the unaffected limb✓ 正解皮膚溫度高於未患肢
- DCapillary refill of 2 seconds毛細血管充盈時間為2秒
— Explanation · 中文詳解 —
石膏過緊容易引發腔室症候群（Compartment Syndrome），導致組織缺血。患肢溫度低於對側肢體顯示血液循環灌流不足，是動脈受壓的警訊。輕微水腫、微血管回流小於 3 秒、能活動腳趾均為正常或可接受的術後恢復範圍。
Cool skin temperature in the affected limb compared to the unaffected side indicates impaired arterial circulation and potential neurovascular compromise, such as compartment syndrome. This finding requires immediate notification of the provider, whereas minimal edema, capillary refill under 3 seconds, and toe movement are expected or acceptable findings.
✦ 台美臨床差異
美國護理師依據神經血管評估 (CMS check) 可自行決定是否拆除石膏；台灣多數需醫師親自評估後才處置。