對於身體活動受限的病人,護理師在協助轉位時應優先採取什麼行動?
Which action should the nurse prioritize to assist a client with impaired physical mobility during transfer?
- AAssess the client's ability to assist✓ 正解評估病人協助的能力
- BPlace the bed at the highest position將病床調至最高位置
- CUse a mechanical lift for every patient為每位病人使用機械式移位機
- DAsk a colleague to help without assessing the patient在未評估病人情況下請同事協助
轉位安全首重評估病人能力。護理師需評估病人是否能負重、能否聽從指令及平衡感,以決定所需的輔助設備與人力。機械懸吊(C)並非對所有病人都是必須;未評估病人能力直接求助(D)會增加作業複雜度;床位過高(B)會增加跌倒風險,轉位時應調至適當高度。
Safe transfer begins with assessment of the client's abilities. The nurse must evaluate whether the client can bear weight, follow directions, and maintain balance in order to determine the required equipment and personnel. A mechanical lift (option C) is not necessary for every client; calling for help without assessing the client (option D) adds to the complexity of the task; and placing the bed at the highest position (option B) increases fall risk—during transfer the bed should be at an appropriate height.
美國醫院非常強調「No-Lift Policy」,對於高風險病人強制使用輔具;台灣則視單位配置而定。