對於診斷為深層靜脈血栓(DVT)的病人,哪些護理措施適當?(選所有適合的)
Which of the following interventions are appropriate for a client diagnosed with deep vein thrombosis (DVT)? (Select all that apply.)
- AEncourage bed rest as prescribed✓ 正解遵照指示鼓勵卧床休息
- BMassage the affected limb to improve circulation按摩患肢以改善循環
- CElevate the affected extremity✓ 正解抬高患肢
- DMonitor for signs of pulmonary embolism✓ 正解監測肺栓塞跡象
- EApply cold compresses to the site在患處應用冷敷
深層靜脈血栓(DVT)的照護重點在於「預防栓子脫落」與「促進靜脈回流」。臥床休息可減少肌肉收縮導致血栓剝落的風險;抬高患肢利用重力促進靜脈血回流,減輕腫脹與不適。護理師需嚴密監測肺栓塞(PE)徵象,如突發性呼吸困難、胸痛或血氧濃度下降,因為這是 DVT 最嚴重的併發症。禁止按摩是為了避免物理性擠壓導致血栓移動。
The focus of care for deep vein thrombosis (DVT) is to prevent the embolus from dislodging and to promote venous return. Bed rest reduces the risk of clot dislodgement from muscular contraction; elevating the affected limb uses gravity to promote venous return, reducing swelling and discomfort. The nurse must closely monitor for signs of pulmonary embolism (PE), such as sudden dyspnea, chest pain, or decreased oxygen saturation, because this is the most serious complication of DVT. Massage is prohibited to avoid mechanical compression that could mobilize the thrombus.