病人出現便秘,下列哪些護理措施是適當的?(選所有適合的)
A client is experiencing constipation. Which nursing interventions are appropriate? (Select all that apply.)
- AIncrease daily fluid intake✓ 正解增加每日液體攝取量
- BEncourage consumption of high-fiber foods✓ 正解鼓勵食用高纖維食物
- CAssist with regular physical activity✓ 正解協助進行規律的身體活動
- DAdminister an enema as the first step將灌腸作為第一步執行
- EProvide privacy during toileting✓ 正解如廁時提供隱私
便秘的處理原則應採「由最少侵入性到最具侵入性」的階梯式護理。首要重點在於調整生活型態,透過增加水分、膳食纖維攝取以及提升活動量來促進腸道蠕動。此外,提供隱私能降低因尷尬產生的心理性抑制,有助於排便反射的啟動。灌腸(Enema)屬於侵入性措施,若非醫囑特別指定,應在基礎護理措施無效後才考慮,以減少腸道依賴與電解質紊亂風險。
Management of constipation should follow a stepwise approach from least to most invasive. The primary focus is on lifestyle modifications, promoting intestinal peristalsis through increased fluid intake, dietary fiber, and physical activity. Providing privacy can also reduce psychological inhibition caused by embarrassment and facilitate the defecation reflex. Enemas are invasive and should be considered only after basic nursing interventions have failed, in order to minimize bowel dependence and the risk of electrolyte imbalance, unless specifically ordered.