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基本照護與舒適 · MEDIUM · SATA

護理師正在為一位有癲癇病史且有受傷風險的病人制定護理計畫。病床邊應準備哪些物品?(選所有適合的)

The nurse is planning care for a client with a history of seizures who is at risk for injury. Which items should be kept at the bedside? (Select all that apply.)

  • AOxygen equipment✓ 正解
    氧氣設備
  • BSuction equipment✓ 正解
    抽吸設備
  • CPadded tongue blades
    包墊的壓舌板
  • DPadded side rails✓ 正解
    包墊的床欄
  • EOral airway
    口咽通氣道
Explanation · 中文詳解

癲癇發作時的護理重點是「維持呼吸道通暢」與「保護病人免於外傷」。氧氣與抽吸設備是標準的床邊預防措施,因為發作後可能出現呼吸抑制或分泌物過多。床欄加護墊(Padded side rails)能減少發作時肢體碰撞造成的瘀傷或骨折。然而,在癲癇發作期間,絕對不能嘗試將任何東西強行塞入病人嘴裡,包括壓舌板或人工氣道,因為這可能導致牙齒斷裂或更嚴重的氣道阻塞。現代護理標準已屏棄壓舌板的使用,這一點在 NCLEX 考試中是高頻考點。

The priorities of nursing care during a seizure are to maintain a patent airway and to protect the client from injury. Oxygen and suction equipment are standard bedside precautions because respiratory depression or excessive secretions may occur after the seizure. Padded side rails reduce contusions or fractures from impact during the seizure. However, during a seizure, nothing should ever be forcibly placed in the client's mouth—including tongue blades or oral airways—as this can break teeth or cause more serious airway obstruction. Modern nursing standards have abandoned the use of tongue blades, a high-yield NCLEX point.

✦ 台美臨床差異

美國各州醫院普遍對「Seizure Precautions」有嚴格的稽核標準,包括四邊床欄加墊;台灣部分醫院則因法規對約束與床欄的限制,或護墊取得不易,有時僅以枕頭代替,但在證照考試中必須選擇標準的 Padded rails。

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