護理師在個案下肢石膏固定兩小時後進行評估。哪些發現需要立即追蹤?請標示與急性腔室症候群相關的發現。 | MyMerci
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Medical Emergencies

護理師在個案下肢石膏固定兩小時後進行評估。哪些發現需要立即追蹤?請標示與急性腔室症候群相關的發現。

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Assessment area評估項目Current finding目前發現
Pain疼痛 Lower-leg pain is 9/10 and persists after intravenous opioid and careful elevation.小腿疼痛為 9/10,靜脈注射鴉片類藥物及小心抬高後仍持續。
Capillary refill微血管回填 Capillary refill in each toe is two seconds, with skin color unchanged from the prior check.每個腳趾微血管回填時間為兩秒,膚色與前次檢查相同。
Swelling腫脹 Moderate swelling at the fracture site has not increased since the cast was applied two hours ago.骨折處中度腫脹,自兩小時前上石膏以來未增加。
Passive movement被動活動 Passive extension of the great toe causes intense pain deep beneath the cast.被動伸展大腳趾引起石膏深處劇烈疼痛。
Pulse脈搏 The dorsalis pedis pulse remains palpable, regular, and equal to the opposite foot.足背動脈仍可觸及、規則且與對側足部相同。
Sensation感覺 New tingling is reported across the toes and the top of the affected foot.個案表示患側足部腳趾及足背新發刺痛感。
Skin皮膚 Bruising remains localized over the fracture and has not spread beyond the marked border.瘀傷仍侷限於骨折處,未擴散至標記邊界外。
Movement運動 The client can no longer lift the great toe as during the previous assessment.個案無法像前次評估時抬起大腳趾。
Temperature溫度 The toes are warm, pink, and match the skin temperature of the unaffected foot.腳趾溫暖、粉紅,且與未受傷足部皮膚溫度一致。
解析
與預期不成比例的疼痛、被動伸展時疼痛、新發感覺異常及新發運動無力,都暗示腔室壓力升高。可觸及的脈搏並不能排除此種威脅肢體的急症。
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