— 基本照護與舒適 · MEDIUM · SATA —
規劃有癲癇病史病人的照護計畫時，下列哪些安全防護措施是必要的？（選所有適合的）
When planning care for a client with a history of seizures, which safety precautions are essential? (Select all that apply.)
- AKeep the side rails up and padded✓ 正解保持床欄拉起並加墊
- BMaintain an oral airway at the bedside在床邊備有口咽導管
- CEnsure suction equipment is available and functional✓ 正解確保抽吸設備可用且功能正常
- DRestrain the client's limbs during the seizure在癲癇發作期間約束病人肢體
- EPlace a padded tongue blade in the client's mouth在病人口中放置加墊的壓舌板
— Explanation · 中文詳解 —
癲癇（Seizure）發作時的護理重點在於防止病人發生外傷（Injury prevention）以及確保氣道通暢（Airway maintenance）。護理策略應預先布局，而非在發作當下進行危險干預。正確的做法是移除周邊危險物品、保護頭部，並在發作後視情況清理呼吸道。過時的處置如強行約束或放入硬物，皆被現行實證護理排除。
Essential safety precautions include keeping padded side rails up to prevent injury from involuntary movements and ensuring suction equipment is functional to maintain a clear airway. These measures prioritize physical protection and respiratory management while avoiding harmful practices like restraint or placing objects in the mouth.
✦ 台美臨床差異
在美國臨床實務中，極度強調「絕不」在發作中嘗試打開病人嘴巴，這在NCLEX中是絕對的Safety優先級選項。