一位術後病人經超音波新診斷出左小腿深層靜脈栓塞（DVT），醫療提供者開立治療劑量的 enoxaparin。哪一項護理行動是優先？
A postoperative client is newly diagnosed by ultrasound with a deep vein thrombosis (DVT) in the left calf, and the provider prescribes therapeutic-dose enoxaparin. Which nursing action is the priority?
- AAdminister the prescribed anticoagulant promptly and monitor for signs of bleeding儘速給予醫囑的抗凝血劑並監測出血徵象正確答案
- BMassage the left calf to relieve discomfort and improve circulation按摩左小腿以減輕不適並促進循環
- CKeep the client on strict bed rest until the calf swelling resolves讓病人嚴格臥床直到小腿腫脹消退
- DApply a sequential compression device to the left leg在左腿裝上間歇性氣動加壓裝置
- A儘速給予醫囑的抗凝血劑並監測出血徵象
正確答案是 A。急性 DVT 治療的核心是立即開始抗凝（低分子量肝素如 enoxaparin、fondaparinux、直接口服抗凝劑或靜脈肝素），以防止血栓延伸、肺栓塞與復發；護理優先是儘速給予醫囑的抗凝血劑，並監測牙齦出血、血尿、黑便、瘀斑等出血徵象與血小板變化。B：按摩患側小腿可能使血栓脫落造成肺栓塞，屬絕對禁忌。C：CHEST 指引建議急性下肢 DVT 病人在抗凝治療下採早期活動而非臥床；嚴格臥床是過時作法，反而加重靜脈鬱滯。抗凝開始後可依耐受度下床，並以抬高患肢與醫囑止痛緩解症狀。D：間歇性氣動加壓裝置是預防血栓的機械方法，肢體已有急性 DVT 時為禁忌，可能使血栓移位。護理另需持續監測突發呼吸困難、胸痛、心搏過速與血氧下降等肺栓塞徵象，一旦出現立即通報。來源：CHEST Guideline and Expert Panel Report, Antithrombotic Therapy for VTE Disease（Kearon et al., 2016；Stevens et al., 2021 update）；Lewis, Medical-Surgical Nursing。
- A · 正確答案儘速給予醫囑的抗凝血劑並監測出血徵象
正確。抗凝是急性 DVT 治療的基石，能防止血栓延伸與肺栓塞；儘速給予醫囑的 enoxaparin 並監測出血徵象是護理優先。
- B按摩左小腿以減輕不適並促進循環
錯誤。按摩患側小腿可能使血栓脫落、造成肺栓塞，是急性 DVT 的絕對禁忌。
- C讓病人嚴格臥床直到小腿腫脹消退
錯誤。嚴格臥床是過時作法；CHEST 指引建議急性下肢 DVT 病人在抗凝治療下早期活動，臥床反而加重靜脈鬱滯。
- D在左腿裝上間歇性氣動加壓裝置
錯誤。間歇性氣動加壓裝置用於預防血栓，患肢已有急性 DVT 時為禁忌，可能使血栓移位。
美國多數單純急性 DVT 病人以低分子量肝素或直接口服抗凝劑在門診或早期出院治療，護理師依院內流程監測 anti-Xa 或腎功能；台灣也使用新型口服抗凝劑（NOAC）。臥床方面，美國已不要求 DVT 病人常規臥床；台灣則仍有醫學中心衛教建議急性期臥床休息 3~5 天以減少肺栓塞，作答時以美國做法為準。 台灣出處：臺中榮民總醫院護理部〈下肢深部靜脈血栓病人之健康維護〉（2026）
English explanation
Option A is correct. The cornerstone of treatment for acute DVT is prompt anticoagulation with a low-molecular-weight heparin such as enoxaparin, fondaparinux, a direct oral anticoagulant, or intravenous heparin, to prevent clot extension, pulmonary embolism, and recurrence. The nurse's priority is to give the prescribed anticoagulant without delay and to monitor for bleeding such as gum bleeding, hematuria, dark stools, and bruising, along with platelet trends. Option B is incorrect because massaging the affected calf can dislodge the thrombus and cause pulmonary embolism; it is absolutely contraindicated. Option C is incorrect because the CHEST guideline suggests early ambulation rather than bed rest for clients with acute leg DVT who are receiving anticoagulation; strict bed rest is outdated and worsens venous stasis. Once anticoagulation has started, the client may ambulate as tolerated, with leg elevation and prescribed analgesia for symptom relief. Option D is incorrect because a sequential compression device is a mechanical method of prophylaxis and is contraindicated on a limb with an acute DVT because it may dislodge the clot. The nurse also monitors for sudden dyspnea, chest pain, tachycardia, and a falling oxygen saturation, which suggest pulmonary embolism and must be reported immediately. Source: CHEST Guideline and Expert Panel Report, Antithrombotic Therapy for VTE Disease (Kearon et al., 2016; Stevens et al., 2021 update); Lewis, Medical-Surgical Nursing.
最近修訂：2026-10-05