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降低風險 · MEDIUM · SATA

護理師照顧一位嗜中性白血球減少症的病患,下列哪些項目應納入照護計畫?(選所有適合的)

A nurse is caring for a client with neutropenia. Which of the following actions should the nurse include in the care plan? (Select all that apply.)

  • ARestrict fresh fruits and vegetables✓ 正解
    限制新鮮水果和蔬菜
  • BInstruct the client to use a soft-bristled toothbrush
    指導病人使用軟毛牙刷
  • CPlace the client in a private room✓ 正解
    將病人安置於單人病房
  • DPerform frequent hand hygiene✓ 正解
    經常執行手部衛生
  • ELimit visitors to healthy adults only✓ 正解
    僅允許健康的成人探視
Explanation · 中文詳解

嗜中性白血球低下會使病患對抗感染能力大幅下降。預防感染措施包括禁止生食(避免微生物)、保護性隔離(單人房)、嚴格執行洗手以減少外源性細菌,以及限制訪客,特別是可能帶有病原體的幼童或生病者。軟毛牙刷主要用於血小板低下(避免出血),而非白血球低下。

Neutropenia significantly reduces the client's ability to fight infection. Infection-prevention measures include avoiding raw foods (to limit microorganisms), protective isolation in a private room, strict hand hygiene to reduce exogenous bacteria, and limiting visitors, particularly young children or anyone who is ill. A soft-bristled toothbrush is mainly used in thrombocytopenia to prevent bleeding, rather than in neutropenia.

✦ 台美臨床差異

美國醫院常見嚴格的 Neutropenic Precautions 標示;台灣亦同步,但在訪客限制的執行力度上,台灣家屬陪伴文化常造成感染風險較高。

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