— 基本照護與舒適 · MEDIUM · MCQ —
病人出現姿位性低血壓。當協助病人下床時，哪項措施最有效？
A client is experiencing orthostatic hypotension. Which nursing action is most effective when assisting the client out of bed?
- AEnsure the client stands up as quickly as possible to avoid falling確保病人儘可能快地站起以避免跌倒
- BHave the client sit on the side of the bed for a few minutes before standing✓ 正解讓病人在站起前先坐在床邊幾分鐘
- CApply a cold compress to the forehead before standing在站起前將冷敷墊放在額頭上
- DImmediately assist the client to the bathroom立即協助病人前往浴室
— Explanation · 中文詳解 —
姿位性低血壓是因為體位改變導致血液滯留於下肢，回心血量驟減。採取「分段式坐起」，讓病人先在床邊坐著（Dangling），給予身體調節血管阻力與心跳的緩衝時間，是預防跌倒與頭暈最簡單有效的護理措施。動作過快會惡化低血壓反應。
To prevent orthostatic hypotension and associated falls, the nurse should have the client sit on the side of the bed for several minutes before standing. This 'dangling' position allows time for hemodynamic adjustments and vascular autoregulation to stabilize blood pressure. Rapid position changes can exacerbate the drop in blood pressure and increase the risk of syncope.
✦ 台美臨床差異
美國護理照護中，評估姿勢性低血壓會納入標準生命徵象紀錄；台灣病房環境中，此動作多依病人主訴彈性執行。