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安全與感染控制 · MEDIUM · SATA

下列哪些措施適用於需要癲癇發作預防的病人?(選所有適合的)

Which of the following interventions are appropriate for a client on seizure precautions? (Select all that apply.)

  • APadding the side rails✓ 正解
    在床欄上加裝軟墊
  • BKeeping oxygen and suction equipment at the bedside✓ 正解
    在床邊備妥氧氣與抽吸設備
  • CRestraining the client to the bed
    將病人約束在床上
  • DPlacing the bed in the lowest position✓ 正解
    將病床調整至最低位置
  • ERemoving restrictive clothing✓ 正解
    鬆開限制性衣物
Explanation · 中文詳解

癲癇發作預防(Seizure precautions)的核心目標在於防止病人於發作時受到物理性傷害。護理措施應著重於環境安全、維持呼吸道通暢以及避免束縛。正確的預防措施包括:加裝床欄軟墊以緩衝碰撞、床邊備妥氧氣與抽吸設備以應對發作後的呼吸道清理、將床位維持在最低高度以預防跌落,以及移除緊身衣物以利呼吸與觀察。約束病人會增加發作時受傷與骨折的風險,因此禁忌使用。

The core goal of seizure precautions is to prevent physical injury to the client during an event. Nursing measures should focus on environmental safety, maintaining airway patency, and avoiding restraints. Appropriate precautions include: padding the side rails to cushion impact, keeping oxygen and suction equipment at the bedside to manage postictal airway clearance, maintaining the bed in the lowest position to prevent fall injury, and removing restrictive clothing to facilitate breathing and observation. Restraining the client increases the risk of injury and fractures during seizures and is therefore contraindicated.

✦ 台美臨床差異

在美國臨床護理中,對於癲癇預防(Seizure Precautions)的設備要求非常嚴謹。床欄軟墊(Side rail pads)在許多機構屬於標準配備。此外,護理師應確保床邊隨時有抽吸器(Suction)並保持開啟狀態,這與台灣部分單位可能僅在發作時才準備設備有所不同。

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