— 基本照護與舒適 · EASY · MCQ —
一位診斷為「床位活動能力受損」的病人，哪項護理介入最為合適？
A client has a nursing diagnosis of 'Impaired bed mobility'. Which intervention is most appropriate?
- ALimit range-of-motion exercises to prevent pain限制關節活動度練習以預防疼痛
- BEncourage the client to help as much as possible✓ 正解鼓勵個案盡可能協助
- CUse a mechanical lift for all transfers所有轉移均使用機械升降設備
- DKeep the bedrails up at all times隨時拉起床欄
— Explanation · 中文詳解 —
針對活動能力受損（Impaired bed mobility）的病人，護理核心目標是維持個案現有的功能性活動度（Functional mobility），防止廢用性症候群（Disuse syndrome）。過度代勞會導致肌肉萎縮、關節攣縮及骨質流失。護理師應評估個案的剩餘能力，並在安全的前提下鼓勵個案主動參與轉位（Transfer）或翻身。這不僅能促進康復，還能提升病人的自我效能感。
The primary goal for a client with impaired bed mobility is to maintain functional mobility and prevent disuse syndrome. Encouraging the client to participate as much as possible in transfers and turning helps preserve muscle strength and promotes independence, whereas over-reliance on assistance or mechanical devices can lead to further deconditioning.
✦ 台美臨床差異
美國非常強調『以病人為中心』的復健，護理師在協助轉位時會運用『無抬舉政策』（No-lift policy）並配合輔具，同時鼓勵個案自我參與，以符合保險給付之復健目標。