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藥理與非經腸給藥 · MEDIUM · MCQ

在給藥過程中病人發生癲癇發作,哪項處置是適當的?

Which of the following interventions is appropriate for a client having a seizure during medication administration?

  • ATurn the client to the side✓ 正解
    將客戶轉為側臥
  • BPlace a padded tongue blade in the mouth
    在口中放入包覆軟墊的舌壓板
  • CImmediately stop the medication and run for help
    立即停止藥物並跑去尋求協助
  • DRestrain the limbs to prevent injury
    約束四肢以防止受傷
Explanation · 中文詳解

癲癇發作(Seizure)時的護理核心為安全(Safety)與呼吸道通暢(Airway)。護理師的首要任務是保護病人頭部,並將其側臥(Side-lying position),以防止嘔吐物或分泌物造成吸入性肺炎(Aspiration)或呼吸道阻塞。過程中應移除周圍危險物品,並記錄發作時間與特徵。絕不可強行約束病人肢體,以免造成骨折或肌肉損傷,亦嚴禁將任何物品放入病人嘴中,以免導致牙齒斷裂或阻塞呼吸道。

The core principles of nursing care during a seizure are safety and maintaining airway patency. The nurse's primary task is to protect the client's head and place them in a side-lying position to prevent vomitus or secretions from causing aspiration pneumonia or airway obstruction. Hazardous objects in the surroundings should be removed, and the duration and characteristics of the seizure should be documented. Forcible restraint of the limbs must never be performed, as it can cause fractures or muscle injury, and nothing should ever be placed in the client's mouth, as it may break teeth or obstruct the airway.

✦ 台美臨床差異

美方臨床教育非常強調「絕對不可」將異物放入發作中病人的口中,台灣部分傳統觀念仍有使用壓舌板的錯誤習慣,需特別矯正。

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