— 降低風險 · MEDIUM · SATA —
以下哪些措施適合下肢深部靜脈栓塞（DVT）的病人？（選所有適合的）
Which of the following interventions are appropriate for a client diagnosed with deep vein thrombosis (DVT) in the lower extremity? (Select all that apply.)
- AMaintain bed rest as prescribed✓ 正解遵照指示維持臥床休息
- BMassage the affected leg to promote circulation按摩患肢以促進循環
- CElevate the affected extremity✓ 正解抬高患肢
- DApply warm, moist compresses to the area✓ 正解在患處應用溫暖濕敷
- EAssess for signs of pulmonary embolism✓ 正解評估肺栓塞跡象
— Explanation · 中文詳解 —
DVT 處置重點為預防血栓脫落引發肺栓塞（PE）。臥床休息可減少血栓脫落機率。抬高患肢促進靜脈回流。溫熱敷可緩解疼痛。絕對嚴禁按摩患肢，因按摩極易導致血栓剝離。護理師需密切觀察是否有胸痛、呼吸急促等 PE 徵象。
DVT management focuses on preventing thrombus dislodgement leading to pulmonary embolism (PE). Bed rest reduces the chance of clot dislodgement. Elevating the affected extremity promotes venous return. Warm compresses relieve pain. Massage of the affected limb is absolutely contraindicated, as it can easily dislodge the thrombus. The nurse must closely monitor for signs of PE, such as chest pain and shortness of breath.
✦ 台美臨床差異
美國對 DVT 照護常有標準化流程圖；台灣臨床護理師對按摩禁忌教育非常重視，但各院對臥床時間長短的指引可能不同。