護理師正準備為病人進行腰椎穿刺。為了減少併發症，護理計畫中應包含哪些措施？（選所有適合的）
A nurse is preparing to perform a lumbar puncture on a client. Which actions should the nurse include in the plan of care to reduce complications? (Select all that apply.)
- AVerify that the informed consent has been signed.✓ 正解確認知情同意書已簽署。
- BInstruct the client to remain flat in bed for 4 to 12 hours after the procedure.✓ 正解指示病人在術後4至12小時內保持平臥。
- CEncourage increased fluid intake following the procedure.✓ 正解鼓勵術後增加水分攝取。
- DApply a warm compress to the puncture site for the first 2 hours.在術後前2小時於穿刺部位敷熱敷。
- EAssess the puncture site for cerebrospinal fluid (CSF) leakage.✓ 正解評估穿刺部位是否有腦脊髓液（CSF）滲漏。
腰椎穿刺的主要風險包括腦脊髓液（CSF）滲漏導致的劇烈頭痛及感染。核心概念是透過正確的姿勢與水分管理來預防穿刺後頭痛。簽署同意書是侵入性醫療程序的基本法律與安全要求。術後要求平臥（Flat）是為了降低椎管內壓力，防止 CSF 從穿刺孔流出。增加液體攝取則有助於促進腦脊髓液的再生。最後，護理師必須密切監測穿刺部位，查看是否有透明液體滲出或血腫形成。選項 D 是錯誤的，因為穿刺後不應立即熱敷，這可能導致血管擴張而增加滲血風險，且可能增加感染機率。
The major risks of lumbar puncture include severe headache from cerebrospinal fluid (CSF) leakage and infection. The core concept is to prevent post-lumbar puncture headache through proper positioning and fluid management. Signing the informed consent is a basic legal and safety requirement for any invasive procedure. Keeping the client flat after the procedure helps lower intraspinal pressure and prevents CSF from leaking through the puncture site. Increasing fluid intake supports CSF regeneration. Finally, the nurse must closely monitor the puncture site for clear fluid leakage or hematoma formation. Option D is incorrect because a warm compress should not be applied immediately after the procedure, since it can cause vasodilation and increase the risk of bleeding, and may also increase the chance of infection.
美國護理常規中，對於術後平臥的時間與水分攝取有非常嚴格的評估與紀錄要求，並強調病人教育；台灣臨床上對於平臥時間（多為6-8小時）與砂袋加壓的使用習慣較為普及，但在 NCLEX 考試中，『平臥』本身才是預防頭痛的核心考點。