— 降低風險 · MEDIUM · MCQ —
病人預計接受腰椎穿刺檢查，術後護理哪項措施是必須的？
A client is scheduled for a lumbar puncture. Which action by the nurse is essential for post-procedure care?
- AMaintain the client in a high-Fowler's position維持病人處於高福勒氏臥位
- BEncourage increased fluid intake✓ 正解鼓勵增加液體攝取
- CLimit the patient's oral intake for 6 hours限制病人經口攝取6小時
- DAssess for leg weakness or sensory deficits評估腿部無力或感覺缺失
— Explanation · 中文詳解 —
腰椎穿刺術後，病人常因腦脊髓液漏出而引發頭痛。增加液體攝取（水分）有助於腦脊髓液的再生成，進而減緩低壓性頭痛。病人通常需要平躺數小時以減壓，不需禁食，觀察重點在於穿刺部位有無紅腫、滲液或腦膜刺激症狀。
After a lumbar puncture, clients often develop headaches due to cerebrospinal fluid (CSF) leakage. Increasing fluid intake (water) helps with CSF regeneration, thereby relieving low-pressure headaches. Clients usually need to lie flat for several hours to reduce pressure, but fasting is not required. Observation focuses on the puncture site for redness, swelling, leakage, or signs of meningeal irritation.
✦ 台美臨床差異
在台灣部分機構仍強烈執行術後平躺 6 小時，美國臨床則視病人狀況靈活調整，更重視水份補充。