護理師照顧一位神經性厭食症病人,在急性期最重要的護理措施為何?
A nurse is caring for a client with anorexia nervosa. Which nursing intervention is the highest priority during the acute phase?
- ADiscussing the client's distorted body image討論客戶扭曲的身體心像
- BEncouraging verbal expression of feelings鼓勵口頭表達感受
- CTeaching relaxation techniques to reduce stress教導放鬆技巧以降低壓力
- DMonitoring daily weight and caloric intake✓ 正解監測每日體重與熱量攝取量
神經性厭食症(Anorexia Nervosa)的急性期護理核心在於「生理安全(Physiological Stability)」。嚴重營養不良可能導致心律不整、低血鉀等致命風險。護理師應運用 ABC 原則(Airway, Breathing, Circulation),優先處理生理需求,待生命徵象穩定後,再進行心理諮商與行為治療。
The cornerstone of acute-phase care in anorexia nervosa is physiological stability. Severe malnutrition can lead to life-threatening complications such as cardiac arrhythmias and hypokalemia. The nurse should apply the ABC principle (Airway, Breathing, Circulation), addressing physiological needs first; psychological counseling and behavioral therapy can be undertaken once vital signs are stable.
美國臨床對於厭食症的照護常涉及多專業團隊(Multidisciplinary team),包括營養師、精神科醫師與心理師,護理師需執行嚴格的『進食監控(Meal observation)』,甚至在進食後限制病人去廁所,以防催吐。