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降低風險 · MEDIUM · SATA

護理師評估長期臥床病人的潛在併發症。護理師應識別出哪些與長期臥床相關的風險?(選所有適合的)

A nurse is assessing a client for potential complications of immobility. Which findings should the nurse identify as risks associated with prolonged bed rest? (Select all that apply.)

  • AFormation of deep vein thrombosis✓ 正解
    深部靜脈血栓的形成
  • BIncreased bone density
    骨密度增加
  • CDevelopment of atelectasis✓ 正解
    肺不張的發展
  • DUrinary stasis and calculi✓ 正解
    尿液滯留與結石
  • EDecreased bowel motility✓ 正解
    腸道蠕動減少
Explanation · 中文詳解

長期臥床(immobility)會對身體各系統產生廣泛的負面影響,導致多種嚴重的併發症。護理師在評估長期臥床病人時,必須全面考慮這些潛在風險,並採取預防措施。這些風險涵蓋了心血管、呼吸、泌尿、消化、肌肉骨骼等多個系統。 正確選項 A、C、D、E 均是長期臥床常見的併發症。長時間不動會導致血液循環緩慢,增加深部靜脈栓塞(DVT)的風險;肺部通氣不足和分泌物積聚會導致肺塌陷(atelectasis)和肺炎;尿液在膀胱中滯留會增加尿路感染和結石的風險;腸道蠕動減少則會引起便秘。這些併發症不僅增加病人的痛苦,更可能延長住院時間,甚至危及生命。因此,護理師必須密切監測並積極介入,以降低這些風險。

Prolonged bed rest increases the risk of deep vein thrombosis due to sluggish circulation, atelectasis from poor lung expansion, urinary stasis leading to infection or stones, and decreased bowel motility causing constipation. Conversely, immobility decreases bone density rather than increasing it, making options A, C, D, and E correct indicators of risk.

✦ 台美臨床差異

美國護理高度強調「Early Mobilization」計畫;台灣醫院亦落實翻身扣背與關節活動度練習。

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