— 生理適應 · MEDIUM · SATA —
一位病患因左小腿深部靜脈栓塞 (DVT) 住院。下列哪些護理措施是適當的？（選所有適合的）
A client is admitted with deep vein thrombosis (DVT) in the left calf. Which nursing interventions are appropriate for this client? (Select all that apply.)
- AMaintain bed rest as ordered✓ 正解依醫囑維持臥床休息
- BMassage the affected calf to improve circulation按摩患側小腿以改善循環
- CElevate the affected extremity✓ 正解抬高患肢
- DApply warm, moist compresses to the area✓ 正解在患部應用溫濕敷料
- EAssess for signs of pulmonary embolism✓ 正解評估肺栓塞的徵象
— Explanation · 中文詳解 —
DVT 照護重點在於預防栓塞脫落引起肺栓塞（PE）。絕對禁止按摩患部，以免血塊剝落。維持絕對臥床、抬高患肢以促進靜脈回流、溫濕敷有助止痛消腫。護理師需密切觀察 PE 徵兆，如胸痛、呼吸困難、心跳過速等。
The focus of DVT care is to prevent clot detachment and pulmonary embolism (PE). Massaging the affected area is strictly prohibited to avoid dislodging the clot. Maintaining strict bed rest, elevating the affected limb to promote venous return, and applying warm, moist compresses help relieve pain and swelling. The nurse must closely monitor for signs of PE, such as chest pain, dyspnea, and tachycardia.
✦ 台美臨床差異
美台臨床對於 DVT 照護原則高度一致，皆強調「不可按摩」及「抗凝血治療」的重要性。