— 照護管理 · MEDIUM · MCQ —
一位老年病人神智混亂並試圖拔除靜脈管路，護理師應先採取什麼行動？
A nurse is caring for an older adult who is confused and pulling at their IV line. What should the nurse do first?
- AAssess the cause of the confusion✓ 正解評估混亂的原因
- BCall the physician for a restraint order聯絡醫師開立約束医嘱
- CApply soft wrist restraints immediately立即施加軟式手腕約束帶
- DAsk a family member to sit with the patient要求家屬坐在病人身邊
— Explanation · 中文詳解 —
護理決策原則是「評估優於干預」。當病人試圖拔除管路時，首要應評估其原因（如譫妄、缺氧、疼痛、尿瀦留、管路不適等）。許多混亂情況是由可逆的生理因素引起，例如低血氧或感染。若先進行約束，可能掩蓋了真正的病因，導致病人狀況惡化。應先找出原因並處理，若仍無法確保病人安全，才考慮使用約束，並需嚴格遵守醫囑與評估流程。
The nurse should first assess the underlying cause of the client's confusion, such as hypoxia, pain, or infection, before intervening. Identifying reversible physiological factors is prioritized over applying restraints, which should only be used as a last resort if safety cannot be ensured. Immediate restraint without assessment may mask the true etiology of the delirium.
✦ 台美臨床差異
美國醫院對於約束（Restraints）的使用有極嚴格的法規限制（JCAHO），必須先嘗試替代方案（如增加陪伴、移除管路干擾），且約束單必須定期重新評估。