— 生理適應 · MEDIUM · SATA —
下列哪些護理措施適用於肺栓塞 (PE) 病人？（選所有適合的）
Which of the following interventions are appropriate for a client diagnosed with pulmonary embolism (PE)? (Select all that apply.)
- AAdminister oxygen as ordered✓ 正解依醫囑給予氧氣
- BPlace in high-Fowler’s position✓ 正解採高半坐臥位
- CMonitor coagulation studies✓ 正解監測凝血功能檢查
- DEncourage early ambulation immediately立即鼓勵早期離床活動
- EAssess for signs of bleeding✓ 正解評估是否有出血跡象
— Explanation · 中文詳解 —
肺栓塞導致血氧不足與呼吸窘迫。護理目標為給氧、維持高半坐臥姿勢以利呼吸。治療涉及抗凝血劑（如肝素），故須監測凝血功能（INR/PT/APTT）並嚴密觀察出血徵象。急性期應嚴格臥床，不可鼓勵下床活動以防栓子脫落。
Pulmonary embolism causes hypoxemia and respiratory distress. Nursing goals include administering oxygen to relieve hypoxemia, placing the client in high-Fowler's to maximize chest expansion, monitoring coagulation studies (PT/INR/aPTT) during anticoagulant therapy, and assessing for bleeding. In the acute phase, strict bed rest is maintained until the clot stabilizes; early ambulation is contraindicated due to risk of further embolization.
✦ 台美臨床差異
美台臨床皆強調肺栓塞的抗凝血監測重要性，美國護理師常參與抗凝治療決策（如調整 heparin drip 速率），台灣則多由醫師調整。