護理師評估一位疑似深部靜脈栓塞(DVT)的病人,下列哪些措施是合適的?(選所有適合的)
A nurse is assessing a client with a suspected DVT. Which interventions are appropriate? (Select all that apply.)
- AElevate the affected extremity✓ 正解抬高患肢
- BAvoid massaging the calf✓ 正解避免按摩小腿
- CAdminister anticoagulants as ordered✓ 正解依指示給予抗凝血劑
- DAmbulate the client frequently to break up the clot頻繁讓病人下床活動以打散血栓
- EApply warm, moist packs✓ 正解應用溫濕敷包
深部靜脈栓塞(DVT)的護理重點在於「防止栓塞脫落」及「緩解症狀」。抬高患肢有助於靜脈回流,減輕水腫;抗凝血劑(Anticoagulants)是治療標準,用於防止栓塞擴大;濕熱敷可緩解血管痙攣與疼痛。最重要的一點是「嚴禁按摩」,因為按摩可能導致血栓斷裂並隨血流進入肺部,引發致命的肺栓塞(PE)。在血栓尚未穩定前,病人必須嚴格臥床(Bed rest)。
Nursing care for deep vein thrombosis (DVT) focuses on 'preventing clot dislodgement' and 'symptom relief.' Elevating the affected extremity promotes venous return and reduces edema; anticoagulants are the standard treatment to prevent clot extension; warm, moist packs help relieve vascular spasm and pain. Most importantly, massage is strictly prohibited because it may cause clot fragmentation and embolization to the lungs, resulting in fatal pulmonary embolism (PE). Until the thrombus is stable, the client must adhere to strict bed rest.