護理師照護一位有癲癇病史的病人。應落實哪些安全措施?(選所有適合的)
A nurse is caring for a client with a history of seizures. Which safety measures should be implemented? (Select all that apply.)
- AKeep the bed in a low position✓ 正解保持病床處於低位
- BPlace padded side rails up✓ 正解拉起加墊護欄
- CKeep a tongue depressor at the bedside在床邊備置舌壓板
- DEnsure suction equipment is available✓ 正解確保抽吸設備可用
- EApply soft restraints to prevent injury施加軟性束帶以防止受傷
癲癇發作(Seizure)的照護核心在於「安全」與「預防受傷」。床低位與加墊護欄是預防病人發作時因劇烈抽搐撞擊床緣而受傷的標準措施。準備抽吸器(Suction)是為了在發作後若病人出現嘔吐,能及時清除呼吸道,防止吸入性肺炎。現代護理實證已證實,放置舌壓板(Tongue depressor)不僅無法防止咬舌,反而可能造成牙齒損傷或導致氣道阻塞,因此絕對禁止使用。束縛(Restraints)則會增加病人掙扎時的受傷風險,非標準照護措施。
Seizure care centers on safety and preventing injury. Keeping the bed low and using padded side rails prevents trauma from convulsive movements. Suction must be ready in case of post-ictal vomiting to prevent aspiration. Modern evidence-based nursing prohibits placing a tongue depressor—it does not prevent tongue biting and may cause dental injury or airway obstruction. Restraints increase injury risk during struggle and are not standard care.