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基本照護與舒適 · MEDIUM · SATA

護理師照護一位癲癇病人,哪些措施屬於癲癇預防(Seizure Precautions)?(選所有適合的)

A nurse is providing care for a client who has a seizure disorder. Which measures are appropriate for seizure precautions? (Select all that apply.)

  • AKeep a suction setup at the bedside✓ 正解
    在床邊備妥抽吸設備
  • BPadded side rails✓ 正解
    包覆軟墊的床欄
  • CKeep the bed in the lowest position✓ 正解
    將病床保持在最低位置
  • DRestrict the client from all physical activity
    限制病人進行所有體力活動
  • EPlace an oral airway in the mouth during the seizure
    在發作期間將口咽通氣管置入口中
Explanation · 中文詳解

癲癇預防的核心是「保護頭部與氣道」。抽吸設備防備嘔吐物誤吸;床欄加墊預防撞擊受傷;低床位防墜。限制所有活動是不人道的,應根據發作頻率評估。絕對不可強行置入東西進入癲癇病人的嘴巴,因為會導致牙齒斷裂或阻塞氣道,這是 NCLEX 常考的錯誤行為。

The core of seizure precautions is to protect the head and airway. Suction equipment guards against aspiration of vomitus; padded side rails prevent injury from impact; a low bed position prevents fall injury. Restricting all activity is inhumane and should be guided by the frequency of seizures. Nothing should ever be forcibly inserted into the mouth of a seizing client, as it can cause tooth fractures or airway obstruction—a common NCLEX-tested wrong action.

✦ 台美臨床差異

美國已不建議使用「壓舌板」等硬物置入;台灣部分傳統照護仍存有此習慣,需透過實證護理推廣更新知識。

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