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降低風險 · MEDIUM · SATA

護理師向心臟衰竭病人進行出院指導,應包含哪些內容?(選所有適合的)

A nurse is reviewing discharge instructions for a client with heart failure. Which instructions should the nurse include? (Select all that apply.)

  • AWeigh yourself daily at the same time each morning✓ 正解
    每天早晨同一時間稱重
  • BLimit fluid intake to 1.5 liters per day✓ 正解
    將每日液體攝取量限制在 1.5 公升
  • CDiscontinue diuretics if dizziness occurs
    若出現頭暈則停用利尿劑
  • DReport weight gain of more than 2 lbs in 24 hours✓ 正解
    若 24 小時內體重增加超過 2 磅則回報
  • EReduce sodium intake to less than 2 g per day✓ 正解
    將鈉攝取量減少至每日少於 2 克
Explanation · 中文詳解

心衰竭出院衛教重點:A. 每日同一時間量體重,是偵測液體滯留最敏感的指標;B. 限水 1.5-2 L/day 可降低心臟前負荷;D. 24 小時體重增加 >2 lbs(或一週 >5 lbs)為失代償紅旗,需立即聯繫醫療團隊;E. 限鈉 <2 g/day 可減少水鈉滯留。C 為錯誤指導:頭暈時不得自行停利尿劑,應回診由醫師調整劑量。

Key points for heart failure discharge education: A. Weighing at the same time each day is the most sensitive indicator for detecting fluid retention; B. Fluid restriction of 1.5-2 L/day reduces cardiac preload; D. Weight gain of >2 lbs in 24 hours (or >5 lbs in a week) is a red flag for decompensation and requires immediate contact with the healthcare team; E. Sodium restriction <2 g/day reduces water and sodium retention. C is incorrect guidance: the patient must not stop the diuretic on their own when dizzy; instead, they should follow up so the physician can adjust the dose.

✦ 台美臨床差異

美國護理師在慢性病管理(含心衰竭)中扮演更主導的角色,常有專責個管師;台灣則較依賴醫師診斷,護理師衛教可能較分散。

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