護理師照護一名下肢裝有外部固定器的病人。哪項評估對於偵測嚴重併發症最重要？
A nurse is caring for a client with an external fixator on the lower leg. Which assessment is the most important to perform to detect a serious complication?
- AAssess the 6 P's (Pain, Pallor, Pulselessness, etc.) for compartment syndrome✓ 正解評估腔室症候群的六大徵象（疼痛、蒼白、無脈搏等）
- BMonitor for low-grade fever監測低度發燒
- CCheck for pin site drainage檢查針孔部位的引流液
- DMeasure the length of the affected leg測量患肢長度
下肢外部固定器 (external fixator) 通常用於治療嚴重骨折，將骨折處固定以促進癒合。然而，骨折或手術本身可能導致組織腫脹，若固定器過緊或組織腫脹嚴重，可能引發腔室症候群 (Compartment Syndrome)。腔室症候群是一種肢體威脅性的急症，因封閉的筋膜腔內壓力升高，壓迫血管和神經，導致血流受阻，若不及時處理，可能造成永久性肌肉和神經損傷，甚至肢體壞死。因此，護理師最重要且優先的評估是偵測腔室症候群的六個 P：疼痛 (Pain)、蒼白 (Pallor)、感覺異常 (Paresthesia)、麻痺 (Paralysis)、無脈 (Pulselessness) 和冰冷 (Poikilothermia)。
Compartment syndrome is a limb-threatening emergency caused by increased pressure within a fascial compartment, which can occur due to swelling or tight fixation after surgery or fracture. The most critical assessment is neurovascular monitoring using the 6 P's (pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia) to detect early signs of vascular compromise and nerve damage.