護理師正在照護一名高跌倒風險的病人，下列哪項行動最為適當？
A nurse is caring for a client who is at high risk for falls. Which action is the most appropriate for the nurse to take?
- AApply a vest restraint for safety穿戴約束衣以確保安全
- BKeep the bed in the lowest position✓ 正解將病床維持在最低位置
- CProvide a bedside commode提供床邊便器
- DAssign a sitter for every client at risk為每位高風險病人指派專人陪伴
預防病人跌倒在臨床照護中是至關重要的安全議題。對於高跌倒風險的病人，護理師應採取多方面的預防措施，其中最基本且非侵入性的策略之一就是確保病床處於最低位置。此舉能有效縮短病人不慎跌落時與地面的距離，顯著降低跌倒造成的傷害嚴重程度，如骨折、頭部外傷等。同時，將病人物品放置在觸手可及的範圍內、確保環境光線充足、移除地面障礙物、提供防滑襪，以及定時巡視等措施，都是綜合性跌倒預防計畫的重要環節。選擇最不具約束性且普遍適用的安全措施，是護理師在保障病人安全時的首要考量。
Preventing patient falls is a critical safety issue. For high-risk patients, the nurse should use multifaceted, least-restrictive interventions. Keeping the bed in the lowest position is one of the simplest, non-invasive, and most effective measures, because it shortens the distance to the floor if a fall occurs and reduces the severity of injuries such as fractures or head trauma. Other measures include keeping items within reach, ensuring adequate lighting, removing obstacles, providing non-slip footwear, and performing scheduled rounds. Choosing the least restrictive yet broadly applicable safety measure is the priority.
在預防跌倒的策略上，台灣與美國的臨床實務均強調將病床維持在最低位置、提供防滑措施及環境安全評估。然而，對於約束（restraint）的使用，美國醫療機構通常有更嚴格的規範和文件要求，強調使用約束的必要性、頻率和替代方案的嘗試，以保障病人權益並遵循最不具約束性（least restrictive environment）原則。台灣在約束使用方面雖也有規範，但在某些情境下，實際執行可能仍有差異。