甲狀腺切除術後病患,下列哪些護理措施是合適的?(選所有適合的)
Which of the following nursing interventions are appropriate for a client post-thyroidectomy? (Select all that apply.)
- AKeep a tracheostomy tray at the bedside✓ 正解在床邊準備氣切盤
- BMonitor for signs of hypocalcemia (Trousseau's sign)✓ 正解監測低血鈣徵象(Trousseau氏徵象)
- CEncourage early ambulation and deep coughing鼓勵早期下床活動並深呼吸咳嗽
- DAssess for voice changes or hoarseness✓ 正解評估是否有聲音改變或嘶啞
- EApply a tight neck dressing to prevent bleeding施加緊繃的頸部敷料以預防出血
甲狀腺術後需嚴防喉頭水腫引發呼吸道阻塞(需備氣切盤),且因副甲狀腺誤傷需監測低血鈣(Trousseau's/Chvostek's sign),同時檢查喉返神經受損導致的聲音嘶啞。E 選項:敷料不可過緊,會壓迫氣管導致呼吸困難,且不利觀察血腫。
After a thyroidectomy, the nurse must guard against airway obstruction from laryngeal edema (a tracheostomy tray must be kept at the bedside), monitor for hypocalcemia caused by inadvertent parathyroid injury (Trousseau's/Chvostek's sign), and assess for hoarseness due to recurrent laryngeal nerve damage. Option E is incorrect: the dressing must not be applied too tightly, as this can compress the trachea, cause respiratory difficulty, and obscure observation for hematoma.
台美術後監測重點一致,但在美國醫療體系中,Trousseau's sign 的評估頻率與標準更為嚴格。