針對左下肢深部靜脈栓塞(DVT)的病患,哪些護理措施適當?(選所有適合的)
Which nursing interventions are appropriate for a client diagnosed with DVT in the left leg? (Select all that apply.)
- AKeep the left leg elevated✓ 正解抬高左腿
- BEncourage early ambulation as per policy依規定鼓勵早期下床活動
- CMassage the calf to relieve pain按摩小腿以緩解疼痛
- DAdminister anticoagulant therapy✓ 正解給予抗凝血治療
- EApply warm, moist compresses✓ 正解應用溫濕敷
深部靜脈栓塞(DVT)的治療目標是防止血栓脫落引發肺栓塞(PE)以及促進靜脈回流。抬高患肢可促進靜脈血液回流並減輕水腫;抗凝血劑(如 heparin 或 warfarin)是治療核心,用於防止血栓擴大;溫熱濕敷則可減輕發炎引起的疼痛。按摩患肢為絕對禁忌,因可能導致血栓剝落,造成致命的肺栓塞。早期下床活動應依照臨床醫師指示,通常在抗凝血治療達到治療範圍後才鼓勵。
The treatment goals for deep vein thrombosis (DVT) are to prevent the thrombus from dislodging and causing pulmonary embolism (PE) and to promote venous return. Elevating the affected limb promotes venous return and reduces edema; anticoagulants (such as heparin or warfarin) are the cornerstone of treatment, preventing extension of the thrombus; warm moist compresses can reduce inflammation-related pain. Massage of the affected limb is absolutely contraindicated because it may dislodge the thrombus and cause a fatal pulmonary embolism. Early ambulation should follow the physician's orders and is typically encouraged only after anticoagulation has reached therapeutic levels.