# 護理師正在評估一位接受迴腸造口術後8小時的個案。哪一項發現需要立即追蹤？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=505795&lang=zh-tw  
> language: zh-TW  
> subject: Basic Care and Comfort  
> category: BCC

## 題目

護理師正在評估一位接受迴腸造口術後8小時的個案。哪一項發現需要立即追蹤？

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個案因潰瘍性結腸炎於8小時前接受迴腸造口術。無已知過敏史。過去病史無特殊。

血壓118/72，心跳88，呼吸16，體溫98.8°F (37.1°C)，SpO2 98%（室內空氣）

血紅素11.2 g/dL，白血球9,500/mm³

每4小時測量生命徵象，每4小時評估造口，依耐受度漸進式飲食，依醫囑處理疼痛

個案嗜睡但可喚醒。腹部柔軟，腸音減弱。造口呈暗紫色且表面乾燥。無明顯出血。敷料上有少量漿液血性引流液。

1

濕潤、紅色的造口伴輕微水腫

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2

暗紫色、表面乾燥的造口

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3

敷料上有少量漿液血性引流液

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4

個案主訴輕微切口疼痛，評分3/10

✕

## 解析

健康的新造口應為濕潤、紅色至粉紅色。暗紫色或乾燥的造口表示血流受阻及可能缺血，需要立即評估。濕潤、紅色的造口伴輕微水腫是正常的術後發現。少量漿液血性引流液在術後早期是可預期的。輕微切口疼痛評分3/10是手術後常見的，並不表示緊急情況。

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