針對一位夜間在病房遊走的阿茲海默症病患,下列哪些護理措施適切?(選所有適合的)
Which of the following interventions are appropriate for a client diagnosed with Alzheimer's disease who is wandering the halls at night? (Select all that apply.)
- APlace the client's bed near the nursing station for observation✓ 正解將病床移至護理站附近以便觀察
- BApply physical restraints to keep the client in bed使用身體約束讓病人留在床上
- CProvide adequate lighting in the hallways at night✓ 正解夜間在走廊提供充足的照明
- DEngage the client in structured activity during the day✓ 正解讓病人在白天參與結構化活動
- EEnsure the client has identification tags on their clothing✓ 正解確保病人衣物上有識別標籤
阿茲海默症病人的遊走通常與作息混亂或認知障礙有關。護理重點在於增加安全性與白天的活動消耗體力。A 可增加監測效率;C 防止因視線不明致跌倒;D 調整睡眠週期的標準作法;E 為防走失的安全措施。B 選項為身體約束,需嚴格遵守醫囑且為最後手段,非首選措施。
Wandering in clients with Alzheimer's disease is often related to disrupted daily routines or cognitive impairment. Nursing care focuses on increasing safety and using daytime activity to expend energy. A increases monitoring efficiency; C prevents falls due to poor visibility; D is a standard intervention to regulate the sleep-wake cycle; and E is a safety measure to prevent elopement. Option B, the use of physical restraints, must comply strictly with a provider's order and is reserved as a last resort, so it is not a first-line measure.
美國非常強調「Restraint-free」環境,醫院管理規範極為嚴格;台灣在長照與急性病房中對約束的運用限制較寬鬆。