— 降低風險 · MEDIUM · SATA —
護理師照護一位疑似深部靜脈栓塞（DVT）的病人，下列哪些護理措施正確？（選所有適合的）
A nurse is caring for a client with a suspected deep vein thrombosis (DVT). Which nursing interventions are appropriate? (Select all that apply.)
- AMaintain bed rest as ordered✓ 正解遵照醫囑維持臥床休息
- BMassage the affected leg to improve circulation按摩患肢以改善循環
- CElevate the affected extremity✓ 正解抬高患肢
- DApply warm, moist compresses to the area✓ 正解在患處應用溫濕敷料
- EAssess for signs of pulmonary embolism✓ 正解評估肺栓塞的徵象
— Explanation · 中文詳解 —
處理 DVT 的核心原則是預防栓子脫落造成肺栓塞。絕對禁止按摩患肢，以免將血栓擠入血液循環。臥床休息可減少栓子脫落，抬高患肢有助靜脈回流，溫熱敷能緩解疼痛與血管痙攣，同時必須密切監測有無呼吸窘迫或胸痛等肺栓塞徵兆。
The primary goal in managing DVT is preventing the clot from dislodging and causing a pulmonary embolism. Interventions include maintaining bed rest, elevating the affected limb to promote venous return, and applying warm compresses to reduce pain and inflammation. Massaging the leg is strictly contraindicated as it may dislodge the thrombus.
✦ 台美臨床差異
在美國，DVT 治療現在趨向於儘早開始抗凝血治療並適度下床活動，與傳統嚴格臥床已有差異。台灣臨床仍多遵循傳統臥床醫囑。