護理師照護一位有癲癇病史的病人,應採取哪些措施?(選所有適合的)
A nurse is caring for a client with a history of seizures. Which actions should the nurse perform? (Select all that apply.)
- AKeep a suction setup at the bedside✓ 正解在床邊準備抽吸裝置
- BEnsure side rails are padded✓ 正解確保床欄有軟墊
- CPlace a padded tongue blade at the bedside在床邊放置軟質壓舌板
- DKeep the bed in the lowest position✓ 正解將病床保持在最低位置
- ELoosen any restrictive clothing around the neck✓ 正解鬆開頸部周圍的任何束縛衣物
癲癇(Seizure)發作時的護理重點在於「防護與呼吸道維護」。應確保床邊有抽吸裝置(Suction)以備發作後清除口鼻分泌物;床欄加軟墊預防碰撞傷;床維持最低位以防跌倒。發作時應移除頸部緊束衣物以利呼吸,並將病人頭部側向一邊。現代護理標準已不建議在發作時硬塞物體(如壓舌板)入病人口腔,以免造成牙齒斷裂或異物吸入。
The nursing focus during a seizure is 'protection and airway maintenance.' Suction equipment must be available at the bedside to clear secretions after the seizure; padded side rails prevent impact injuries; the bed should be kept in the lowest position to prevent falls. During a seizure, restrictive clothing around the neck should be loosened to facilitate breathing, and the client's head should be turned to the side. Current nursing standards no longer recommend forcing objects (such as a tongue blade) into the client's mouth during a seizure, as it can cause dental fractures or foreign body aspiration.