一位病人因右下肢深層靜脈栓塞(DVT)入院。護理師應「避免」哪項措施?
A client is admitted with a diagnosis of deep vein thrombosis (DVT) in the right leg. Which action should the nurse avoid?
- AApplying warm compresses as ordered依醫囑施加溫熱敷
- BMassaging the affected calf✓ 正解按摩患側小腿
- CAdministering anticoagulant medications給予抗凝血藥物
- DElevating the affected extremity抬高患肢
深層靜脈栓塞(DVT)的病人患肢內存在血栓,按摩患肢是絕對禁忌(Contraindicated)。按摩的物理壓力極可能導致血栓脫落,脫落的血栓(栓子)會隨血液循環流向右心房、右心室,最後進入肺動脈,造成肺栓塞(Pulmonary Embolism, PE),這是一種危及生命的急症。照護重點在於預防血栓移動,而非促進血液循環。
A patient with deep vein thrombosis (DVT) has a thrombus in the affected extremity, and massaging the leg is absolutely contraindicated. The physical pressure of massage can dislodge the thrombus, and the resulting embolus travels through the circulation to the right atrium, the right ventricle, and on into the pulmonary artery, producing pulmonary embolism (PE), a life-threatening emergency. Care therefore focuses on preventing movement of the thrombus rather than on promoting circulation.