病人已臥床數日。第一次協助其下床時,護理師應先做什麼?
A client has been on bed rest for several days. When getting the client up for the first time, what should the nurse do first?
- AHave the client stand up quickly to test balance讓病人快速站起以測試平衡
- BProvide a walker and encourage rapid walking提供助行器並鼓勵快速行走
- CDangle the client's legs over the side of the bed✓ 正解讓病人雙腿懸垂於床緣
- DApply a transfer belt after the client stands在病人站起後使用移位帶
對於長期臥床的病人,由於缺乏活動,其心血管系統對姿勢變化的調節能力會下降,導致體位性低血壓(orthostatic hypotension)的風險增加。當病人從平躺快速轉為站立時,血液可能迅速積聚在下肢,導致腦部供血不足,引起頭暈、虛弱,甚至暈厥和跌倒。因此,在第一次協助病人下床時,護理師應採取漸進式的方法。 讓病人「垂足坐位」(Dangle the client's legs over the side of the bed)是重要的第一步。這讓病人坐在床緣,雙腳自然下垂,讓身體有時間適應重力對循環系統的影響,使血壓和心率逐漸穩定,顯著降低體位性低血壓和跌倒的風險。臨床思路方面,病人的安全和跌倒預防永遠是首要考量。
Prolonged bed rest impairs the cardiovascular system's ability to regulate blood pressure during position changes, increasing the risk of orthostatic hypotension. Dangling the client's legs over the side of the bed is the critical first step, allowing the body to gradually adapt to gravity and stabilize heart rate and blood pressure before attempting to stand.
美國法規嚴格要求使用 Gait belt (移位帶);台灣臨床使用率較低,常由多人攙扶。