— 降低風險 · MEDIUM · SATA —
腰椎穿刺術後，下列哪些護理措施為優先事項？（選所有適合的）
Which of the following nursing interventions is the priority for a client following a lumbar puncture? (Select all that apply.)
- AMaintain a flat supine position for several hours✓ 正解維持數小時的平臥位
- BEncourage increased fluid intake to replace CSF volume✓ 正解鼓勵增加水分攝取以補充腦脊髓液容量
- CMonitor the puncture site for leakage or hematoma✓ 正解監測穿刺部位是否有滲漏或血腫
- DAdminister high-dose opioids immediately立即給予高劑量鴉片類止痛藥
- EAssess for sensory or motor deficits in lower extremities✓ 正解評估下肢是否有感覺或運動缺失
— Explanation · 中文詳解 —
腰椎穿刺後為預防頭痛（spinal headache），需維持平躺以減少腦脊髓液漏出。補充水分有助於產生腦脊髓液。術後需觀察穿刺點有無出血及神經學症狀，以排除血腫壓迫。高劑量鴉片類藥物非首選，應先觀察與維持體位。
After a lumbar puncture, the client should remain supine to minimize cerebrospinal fluid leakage and prevent a spinal headache. Increased fluid intake helps replenish CSF production. Postprocedure monitoring of the puncture site for bleeding and assessment of neurologic symptoms are required to rule out hematoma-related nerve compression. High-dose opioids are not first-line; observation and positioning should take precedence.
✦ 台美臨床差異
台灣醫院通常會要求病人平躺 4-6 小時，美國部分機構視情況已縮短此限制，但平躺仍是常見建議。