— 基本照護與舒適 · HARD · SATA —
進行姿勢性低血壓評估時，正確步驟為何？（選所有適合的）
When assessing for orthostatic hypotension, what are the correct steps? (Select all that apply.)
- AMeasure BP while the client is supine✓ 正解在病人仰臥時測量血壓
- BMeasure BP immediately after the client stands up✓ 正解在病人站起後立即測量血壓
- CMeasure BP after the client has stood for 3 minutes✓ 正解在病人站立 3 分鐘後測量血壓
- DPerform the assessment rapidly to save time快速進行評估以節省時間
- EEnsure the client does not move during measurement確保病人在測量期間保持不動
— Explanation · 中文詳解 —
姿勢性低血壓（Orthostatic hypotension）評估的關鍵在於捕捉血壓隨重力改變的代償反應。正確的評估步驟要求病人由平躺轉為站立，並在不同時間點測量血壓。若收縮壓下降超過 20 mmHg 或舒張壓下降超過 10 mmHg，即視為陽性。護理師需確保病人站立後有足夠時間讓生理代償機制（如心跳加速、血管收縮）反映出來。
Accurate assessment of orthostatic hypotension requires measuring blood pressure while the client is supine as a baseline, then immediately and again after three minutes of standing. This timing allows for the evaluation of the physiological compensatory response to gravity; rapid assessment or moving the client during measurement can lead to inaccurate results.