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照護管理 · EASY · SATA

護理師照顧一位有跌倒病史的病人,應採取哪些預防措施?(選所有適合的)

A nurse is caring for a client with a history of falls. Which fall prevention measures should be implemented? (Select all that apply.)

  • AKeep the bed in the lowest position✓ 正解
    保持病床處於最低位置
  • BKeep the call light within reach✓ 正解
    將呼叫鈴置於患者可觸及之處
  • CEncourage the use of non-slip socks✓ 正解
    鼓勵穿著防滑襪
  • DApply physical restraints to keep the patient in bed
    使用身體約束具以限制患者留在床上
  • EPlace the client in a room near the nursing station✓ 正解
    將患者安置於靠近護理站的病房
Explanation · 中文詳解

防跌措施重點在於環境安全與適度監控。降低床位(A)、呼叫鈴隨手可得(B)、穿防滑襪(C)與安排靠近護理站之房間(E)皆為標準預防策略。D(身體約束)為最後手段,僅在確實危害生命且其他非侵入措施無效時才考慮,不可作為常規防跌措施。

The focus of fall prevention is environmental safety and appropriate monitoring. Keeping the bed in the lowest position (A), having the call light within reach (B), wearing non-slip socks (C), and assigning a room near the nursing station (E) are standard preventive strategies. Option D (physical restraint) is a last resort, used only when life is genuinely endangered and other non-invasive measures have failed; it should not be considered a routine fall prevention measure.

✦ 台美臨床差異

美國『跌倒風險評估』與相關指標監測極嚴;台灣醫院亦有完整的跌倒評估表,但在家屬參與照護時,衛教需同時包含家屬。

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