護理師照顧一位懷疑深層靜脈栓塞(DVT)的病人。應採取哪些行動?(選所有適合的)
A nurse is caring for a client with a suspected deep vein thrombosis (DVT). Which actions should the nurse perform? (Select all that apply.)
- AMassage the affected leg to promote circulation按摩患肢以促進循環
- BKeep the client on strict bed rest as ordered✓ 正解遵照指示讓病人嚴格卧床休息
- CElevate the affected limb✓ 正解抬高患肢
- DApply warm compresses to the area✓ 正解在患處應用溫敷
- EEncourage the client to walk frequently鼓勵病人經常行走
DVT 的護理核心在於「禁止揉捏、預防脫落」。按摩患肢可能導致血栓脫落引發肺栓塞,是絕對禁忌。應讓病人絕對臥床休息並抬高患肢以減輕水腫與促進靜脈回流。溫敷可促進局部血液循環與緩解不適。活動則需在抗凝血劑治療下,經醫師評估才可進行。
The core of DVT nursing care is to avoid kneading and prevent thrombus dislodgement. Massaging the affected leg may cause the thrombus to dislodge and trigger pulmonary embolism, and is therefore absolutely contraindicated. The client should be placed on strict bed rest and the affected limb should be elevated to reduce edema and promote venous return. Warm compresses can promote local circulation and relieve discomfort. Ambulation is permitted only after evaluation by the provider once anticoagulation therapy has taken effect.
美國醫院越來越傾向於在特定狀況下儘早使用壓力襪及抗凝血治療,台灣則較保守,通常維持絕對臥床至症狀緩解。