護理師照護癲癇發作病史的病人,應採取哪些措施以確保病人安全?(選所有適合的)
A nurse is caring for a client with a history of seizures. Which interventions should the nurse prioritize to ensure patient safety? (Select all that apply.)
- APad the side rails of the bed✓ 正解在床欄上鋪設軟墊
- BKeep oral suction equipment at the bedside✓ 正解將口腔吸引設備置於床邊
- CPlace the client in a prone position during the seizure在發作期間讓患者採取俯臥姿勢
- DEnsure O2 equipment is readily available✓ 正解確保氧氣設備隨時可用
- EApply soft wrist restraints to prevent injury使用軟質手腕約束帶以防止受傷
癲癇(Seizure)病人的護理首重安全與呼吸道通暢。發作期間,護理師應保護病人頭部避免碰撞,並確保抽吸設備與氧氣就位。床欄加墊是標準安全措施,防止病人痙攣撞傷。注意,發作時不應強行約束或放入硬物,且應將病人側臥(側臥位,Side-lying position)以促進口腔分泌物引流,防止吸入性肺炎。
Nursing care of a patient with seizures focuses first on safety and a patent airway. During a seizure, the nurse should protect the patient's head from injury and ensure that suction equipment and oxygen are in place. Padded side rails are a standard safety measure to prevent injury from convulsions. Note that during a seizure the patient must not be forcibly restrained and no hard object should be placed in the mouth; the patient should be placed in a side-lying position to facilitate drainage of oral secretions and prevent aspiration pneumonia.