— 降低風險 · MEDIUM · MCQ —
護理師照護一位剛進行完腰椎穿刺的病人。下列哪項護理措施在術後最為適當？
A nurse is caring for a client undergoing a lumbar puncture. Which nursing action is most appropriate post-procedure?
- APlace the client in a high-Fowler’s position將病人置於高福勒氏臥位
- BApply a warm compress to the puncture site在穿刺部位敷熱敷
- CInstruct the client to remain flat in bed✓ 正解指示病人保持平臥於床上
- DEncourage immediate ambulation to prevent stiffness鼓勵立即下床活動以預防僵硬
— Explanation · 中文詳解 —
腰椎穿刺（Lumbar Puncture, LP）後，最常見的併發症是腦脊髓液（CSF）外漏導致的低腦壓頭痛（Post-dural puncture headache）。維持平臥姿勢可利用重力減緩 CSF 從硬腦膜穿刺點持續流失，並促進穿刺點癒合。護理師需確保病人術後依醫囑平臥，並密切觀察穿刺部位有無滲漏。
Post-lumbar puncture, the client should remain flat to minimize the risk of a post-dural puncture headache caused by cerebrospinal fluid leakage. Maintaining a supine position helps reduce hydrostatic pressure at the puncture site, facilitating closure and preventing further CSF loss. Ambulation or sitting upright may exacerbate the headache by increasing fluid drainage.