護理師督導護理佐理員(UAP)照顧癲癇病史病人時,觀察到哪種情況需要立即介入?
A nurse is supervising an unlicensed assistive personnel (UAP) who is providing care for a client with a history of seizures. Which observation requires immediate nurse intervention?
- AThe UAP places a padded tongue blade in the client's mouth during a seizure✓ 正解護理佐理員在病人發作期間將包紮過的舌片放入其口中
- BThe UAP records the duration of the seizure activity護理佐理員記錄發作活動的持續時間
- CThe UAP loosens the clothing around the client's neck護理佐理員鬆開病人頸部的衣物
- DThe UAP places the client in a side-lying position護理佐理員將病人置於側臥位
現代癲癇急救指引禁止在發作期間強制將異物放入病人口中,因為這極易導致牙齒斷裂、軟組織損傷或呼吸道阻塞。護理師應立即制止該行為,並教育 UAP 癲癇發作時的標準防護程序是維持呼吸道通暢、保護頭部及側臥以利分泌物流出。
Current seizure first-aid guidelines prohibit forcibly placing any object into the client's mouth during a seizure, as this can readily cause tooth fracture, soft-tissue injury, or airway obstruction. The nurse should immediately stop this action and educate the UAP that the standard protective measures during a seizure are maintaining a patent airway, protecting the head, and turning the client side-lying to allow secretions to drain.
美台臨床對於癲癇急救原則一致,皆強調不再使用壓舌板,但在台灣部分資深人員可能仍有舊觀念,需強化教育。