— 安全與感染控制 · MEDIUM · SATA —
護理師檢視防跌倒安全協議，下列哪些措施適合高跌倒風險的病人？（選所有適合的）
A nurse is reviewing safety protocols to prevent patient falls. Which interventions are appropriate for a client at high risk for falls? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將病床調整至最低位置
- BApply vest restraints to keep the client in bed使用背心式約束帶讓病人留在床上
- CPlace the client in a room close to the nursing station✓ 正解將病人安置在靠近護理站的房間
- DEncourage the client to call for assistance before getting up✓ 正解鼓勵病人在起身前請求協助
- EEnsure the call light is within reach✓ 正解確保呼叫鈴在可及範圍內
— Explanation · 中文詳解 —
防跌倒應採取非約束性措施為主，包括調整床位高度、安排靠近護理站以便監測、衛教病人呼叫協助，以及確保呼叫鈴在手邊。約束（如背心式限制）為極端且最後的手段，需嚴格的醫療評估與適應症，不應作為防跌倒的優先或常規措施。
Appropriate fall prevention interventions include keeping the bed in the lowest position, placing the client near the nursing station for frequent observation, encouraging the client to call for assistance, and ensuring the call light is within reach. Vest restraints are not recommended as they may increase agitation and fall risk.
✦ 台美臨床差異
台灣醫院對約束使用較為嚴格，需符合特定法規；美國同樣強調約束為最後手段，且需頻繁評估與解開。