護理師照護一位疑似深層靜脈栓塞(DVT)的病人,應避免哪項行動?
A nurse is caring for a client with a suspected DVT. Which action should the nurse avoid?
- AAssessing for Homan's sign✓ 正解評估霍曼氏徵象
- BAdministering prescribed analgesics給予處方止痛藥
- CElevating the affected extremity抬高患肢
- DApplying warm compresses to the area在患處應用熱敷
深層靜脈栓塞(DVT)的照護重點在於預防血栓脫落引發肺栓塞(PE)。Homan's sign(小腿背屈測試)雖然是舊時檢查 DVT 的方法,但因該動作會擠壓小腿深層靜脈,極易導致血栓脫落,現已被臨床嚴格禁止用於疑似 DVT 的病人。照護重點應轉為抬高患肢以促進靜脈回流、給予熱敷以減緩疼痛,以及規律給予抗凝血劑與止痛藥。安全第一,避免物理性刺激患肢是關鍵。
The focus of care for deep vein thrombosis (DVT) is to prevent dislodgement of the clot and the resulting pulmonary embolism (PE). Although Homan's sign (calf dorsiflexion test) was previously used to assess for DVT, this maneuver compresses the deep veins of the calf and can easily dislodge a thrombus; it is now strictly prohibited in clinical practice for clients with suspected DVT. Care should focus on elevating the affected extremity to promote venous return, applying warm compresses to relieve pain, and administering anticoagulants and analgesics as scheduled. Safety is paramount, and avoiding physical stimulation of the affected limb is essential.