護理師照顧一位有跌倒病史的病人,應採取哪項措施以降低進一步受傷的風險?
A nurse is providing care to a client who has a history of falls. Which action should the nurse take to reduce the risk of further injury?
- AKeep the bed in the highest position將床維持在高位置
- BApply physical restraints as a precaution作為預防措施應用身體約束
- CPlace the client in a room far from the nursing station將病人安置在遠離護理站的房間
- DEnsure the call light is within reach✓ 正解確保呼叫鈴在可觸及範圍內
預防跌倒(Fall Prevention)是護理照護的基本安全指標。護理師應透過環境評估與病人教育來降低風險。將呼叫鈴(Call light)置於病人隨手可得之處,能滿足病人需求並防止其因嘗試自行下床而發生跌倒。環境安全措施亦包括床位保持低位(Low position)、防滑襪的使用,以及若病人意識混亂則考慮靠近護理站。
Fall prevention is a fundamental safety indicator of nursing care. The nurse should reduce risk through environmental assessment and patient education. Placing the call light within the patient's reach allows the patient's needs to be met and prevents falls that may occur when the patient attempts to get out of bed alone. Environmental safety measures also include keeping the bed in a low position, using non-slip socks, and, if the patient is confused, locating them near the nurses' station.