護理師照護一位有癲癇病史的病人,應採取哪些安全預防措施?(選所有適合的)
A nurse is caring for a client with a history of seizures. Which safety precautions should the nurse implement? (Select all that apply.)
- AKeep padded side rails up✓ 正解保持加墊床欄升起
- BMaintain a suction setup at the bedside✓ 正解在床邊準備抽吸設備
- CInsert a tongue blade during the seizure在癲癇發作期間插入壓舌板
- DKeep oxygen equipment ready for use✓ 正解準備好氧氣設備以備使用
- ERestrict all physical activity限制所有身體活動
癲癇病人的安全照護重點在於防護與呼吸道維護。床欄加墊可防止強直陣攣發作時的碰撞傷害;準備抽吸設備(Suction)是為了在發作後若有嘔吐或分泌物時,能立即清理呼吸道;準備氧氣設備則因發作後病人常有缺氧現象。絕對禁止在發作時向病人口中放置任何東西(如壓舌板),因這會導致牙齒斷裂或阻塞氣道。限制活動非必要,應鼓勵病人過正常生活。
The key to safety in caring for clients with seizures is injury prevention and airway maintenance. Padded side rails prevent impact injuries during tonic-clonic seizures; suction equipment is prepared so that any vomitus or secretions can be cleared from the airway immediately after the seizure; oxygen equipment is prepared because hypoxia often occurs in the post-ictal phase. Placing anything (such as a tongue blade) into the client's mouth during a seizure is strictly forbidden, as it can fracture teeth or obstruct the airway. Restriction of all activity is not necessary; the client should be encouraged to lead a normal life.