護理師照顧一位有癲癇病史的病人,下列哪些屬於預防癲癇發作的照護措施?(選所有適合的)
A nurse is caring for a client with a history of seizures. Which interventions are appropriate for seizure precautions? (Select all that apply.)
- AKeep padded side rails up at all times✓ 正解隨時保持軟墊床欄升起
- BEnsure suction equipment is available at the bedside✓ 正解確保床邊備有抽吸設備
- CMaintain the bed in the lowest position✓ 正解保持病床處於最低位置
- DPlace a padded tongue blade at the bedside在床邊放置軟墊舌壓板
- EEstablish an IV access for emergency medication✓ 正解建立靜脈通路以備緊急用藥
癲癇預防的核心是維持安全與呼吸道通暢。需確保床欄加上軟墊以防碰撞,床位降至最低以防墜床,並備妥抽吸設備以利處理發作時的唾液或嘔吐物。建立靜脈通路(IV)是為了發作時能迅速投藥。現代護理實務嚴禁在病人發作時放入壓舌板或任何硬物,以免導致牙齒斷裂或阻塞呼吸道。
The core of seizure precautions is maintaining safety and a patent airway. Padded side rails are used to prevent injury, the bed is kept in the lowest position to prevent falls, and suction equipment is kept ready to manage saliva or vomit during a seizure. Establishing IV access allows rapid administration of medication if a seizure occurs. Current nursing practice strictly prohibits placing a padded tongue blade or any hard object in the mouth during a seizure, as this can cause tooth fracture or airway obstruction.
兩地均已廢除放置壓舌板的常規,但美國護理單位對執行抗癲癇藥物給予的醫囑執行權限較為靈活。