— 基本照護與舒適 · MEDIUM · SATA —
護理師應採取哪些介入措施來預防長期臥床病人的不動併發症？（選所有適合的）
Which of the following interventions should a nurse implement to prevent complications of immobility in a bedridden client? (Select all that apply.)
- AReposition the client every 2 hours✓ 正解每 2 小時為病人更換姿勢
- BEncourage deep breathing and coughing exercises✓ 正解鼓勵進行深呼吸和咳嗽運動
- CAdminister prophylactic anticoagulants as ordered✓ 正解依醫囑給予預防性抗凝血劑
- DProvide high-protein, high-calorie nutrition✓ 正解提供高蛋白、高熱量營養
- ELimit fluid intake to prevent incontinence限制水分攝取以防止失禁
— Explanation · 中文詳解 —
長期臥床病人極易發生多重併發症，包括壓瘡（immobility-related ulcers）、肺炎（atelectasis/pneumonia）、深層靜脈栓塞（DVT）及肌肉萎縮。護理照護計畫必須全面涵蓋：翻身預防受壓、呼吸運動預防肺部塌陷、預防性抗凝血劑降低血栓風險、以及高營養補充以維持組織修復能力。
Bedridden clients are highly susceptible to multiple complications, including pressure injuries, pneumonia (atelectasis/pneumonia), deep vein thrombosis (DVT), and muscle atrophy. The nursing care plan must comprehensively include: repositioning to prevent pressure injury, breathing exercises to prevent pulmonary atelectasis, prophylactic anticoagulants to reduce thrombosis risk, and high-nutrition support to maintain tissue repair capacity.