護理師正在照顧一位有癲癇病史的病人,下列哪些措施應包含在癲癇預防措施中?(選所有適合的)
A nurse is caring for a client with a history of seizures. Which actions should the nurse include in the client's seizure precautions? (Select all that apply.)
- AKeep a suction setup at the bedside✓ 正解在床邊準備抽吸設備
- BPad the side rails of the bed✓ 正解為床欄加裝軟墊
- CKeep the bed in the lowest position✓ 正解將病床保持在最低位置
- DRestrict the client from using any electronic devices限制病人使用任何電子裝置
- EPlace an oral airway at the bedside在床邊放置口咽通氣道
癲癇預防措施(seizure precautions)的目標在於預防病人在發作時受傷。環境安全至關重要,包括維持床鋪在最低高度以防跌落、床欄加軟墊以防碰撞。此外,因癲癇發作時病人可能出現嘔吐或分泌物增多,床邊必須準備抽吸設備以防止吸入性肺炎。護理師應特別注意,絕不可在病人痙攣時強行將任何物體(包括口腔呼吸道)放入病人口中,以免導致牙齒斷裂或氣道阻塞。
The goal of seizure precautions is to prevent injury during a seizure. Environmental safety is essential, including keeping the bed in the lowest position to prevent falls and padding the side rails to prevent injury from contact. In addition, because the client may have vomiting or increased secretions during a seizure, suction equipment must be available at the bedside to prevent aspiration pneumonia. The nurse should be aware that no object (including an oral airway) should ever be forced into the client's mouth during convulsions, as this may cause dental injury or airway obstruction.