— 降低風險 · MEDIUM · SATA —
護理師照護一位接受腰椎穿刺的病人。下列哪些護理措施是適當的？（選所有適合的）
A nurse is caring for a client undergoing a lumbar puncture. Which nursing actions are appropriate? (Select all that apply.)
- APosition the client in a side-lying fetal position✓ 正解將病人置於側臥屈曲姿勢
- BInstruct the client to remain flat for several hours post-procedure✓ 正解指示病人在術後保持平躺數小時
- CEncourage fluid intake after the procedure✓ 正解鼓勵術後攝取足夠水分
- DAssess the puncture site for leakage of cerebrospinal fluid✓ 正解評估穿刺部位是否有腦脊髓液滲漏
- ERequire the client to be NPO for 24 hours prior to the procedure要求病人在術前禁食24小時
— Explanation · 中文詳解 —
腰椎穿刺是採集腦脊髓液的檢查。術中需採側臥蜷曲姿勢以擴大腰椎間隙；術後平躺數小時可降低腦脊髓液滲漏導致頭痛的機率；補充足夠水分能加速腦脊髓液產生；檢查穿刺處是否有滲漏、紅腫或血腫。E 錯誤，腰穿術前通常不需禁食，除非有特殊麻醉需求。
Appropriate nursing actions include positioning the client in a side-lying fetal position to widen intervertebral spaces and instructing them to remain flat post-procedure to reduce the risk of spinal headaches. Additionally, encouraging fluid intake aids in replenishing cerebrospinal fluid, while monitoring the puncture site ensures early detection of leakage or infection.
✦ 台美臨床差異
美台對於腰穿術後平躺時間的規定略有差異，部分美國中心已縮短平躺時間，台灣則多維持傳統建議以減少頭痛發生。