— 生理適應 · HARD · MCQ —
護理師照護疑似脊髓損傷的病人時，應優先採取哪項措施？
Which of the following actions should the nurse prioritize when caring for a client with a suspected spinal cord injury?
- AAdminister pain medication給予止痛藥物
- BAssess motor function in all extremities評估四肢運動功能
- CInsert a Foley catheter插入福來氏導尿管
- DMaintain spinal immobilization✓ 正解維持脊椎固定
— Explanation · 中文詳解 —
脊髓損傷處置的核心原則是「防止二次損傷」。在未排除脊椎骨折或損傷前，必須維持脊椎固定（頸圈、長背板）。若隨意移動或未固定，可能導致神經組織進一步受損甚至造成永久性癱瘓。運動功能評估與插尿管皆為後續處置，必須在脊椎被妥善保護的前提下進行。
The cornerstone of suspected spinal cord injury management is prevention of secondary injury. Until spinal fracture or injury is ruled out, immobilization (cervical collar, long backboard) must be maintained. Moving the client without proper immobilization may cause further neurologic damage or permanent paralysis. Motor assessment and catheterization are performed after the spine has been adequately protected.
✦ 台美臨床差異
美國 EMT 與急診護理師在脊椎固定與轉運流程非常嚴謹，台灣同樣遵循 ATLS 準則進行固定。