護理師照護有癲癇病史的病人,應包含哪些照護計畫內容?(選所有適合的)
A nurse is managing the care of a client with a history of seizures. Which interventions should the nurse include in the client's plan of care? (Select all that apply.)
- AKeep the side rails of the bed up and padded✓ 正解保持床欄拉起並加墊軟墊
- BMaintain suction equipment at the bedside✓ 正解在床邊準備吸引設備
- CPlace a tongue blade in the mouth during a seizure在抽搐期間將壓舌板放入口中
- DLoosen any clothing around the neck or chest✓ 正解鬆開頸部或胸部周圍的任何衣物
- EEnsure the client has oxygen and an Ambu bag available✓ 正解確保個案有可用氧氣及 Ambu bag(自動呼吸器)
癲癇發作的護理重點在於「病人安全」與「呼吸道維持」。在發作期間,重點是保護頭部與身體免受碰撞外傷,因此床欄需加墊軟墊。發作後,病人常有意識混亂或呼吸道阻塞風險,需隨時備妥吸引器與氧氣設備。絕對禁止強行放入異物(如壓舌板),以免造成牙齒斷裂或阻塞氣道。鬆開頸部衣物能減少對呼吸的限制,確保發作後的氧氣供應。
Nursing care for seizures emphasizes patient safety and airway maintenance. During the seizure, the priority is to protect the head and body from trauma, so padded side rails are required. After the seizure, the client is at risk of confusion or airway obstruction, so suction and oxygen equipment must be available at all times. Forcing objects (such as a tongue blade) into the mouth is absolutely prohibited because it can cause tooth fractures or airway obstruction. Loosening clothing around the neck reduces respiratory restriction and helps ensure oxygenation after the seizure.