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降低風險 · HARD · SATA

一位疑似深層靜脈血栓(DVT)的病人入院,下列哪些護理措施是適當的?(選所有適合的)

A client is admitted with a suspected DVT. Which nursing interventions are appropriate for this client? (Select all that apply.)

  • AAmbulate the client frequently
    頻繁讓病人下床走動
  • BElevate the affected extremity✓ 正解
    抬高患肢
  • CApply warm, moist compresses to the area✓ 正解
    在患處施加溫熱濕敷
  • DMassage the affected area to promote circulation
    按摩患處以促進血液循環
  • EAdminister ordered anticoagulants✓ 正解
    給予處方之抗凝血劑
Explanation · 中文詳解

核心概念:深層靜脈血栓(Deep Vein Thrombosis, DVT)的護理原則。 為何正確答案對: B. 抬高患肢(Elevate the affected extremity)有助於減輕靜脈回流壓力,緩解腫脹和疼痛,並減少血液淤積,進而降低血栓形成的風險。 C. 溫熱、濕敷(Warm, moist compresses)可以促進血液循環,緩解局部疼痛和腫脹,有助於改善 DVT 的症狀。 E. 抗凝血劑(Anticoagulants),如肝素(Heparin)或低分子量肝素(Low-molecular-weight heparin, LMWH),是 DVT 的標準治療,它們能抑制血栓的擴大,並預防新的血栓形成。 為何其他選項錯: A. 頻繁走動(Ambulate the client frequently)在急性 DVT 期應避免,因為活動可能導致血栓脫落,引發致命的肺栓塞(Pulmonary Embolism, PE)。病人通常需要臥床休息,直到抗凝血治療穩定血栓。 D. 按摩患肢(Massage the affected area)是絕對禁忌。按摩可能導致已形成的血栓脫落,引發肺栓塞,這是 DVT 最危險的併發症。 臨床思路(Safety/Physiological Adaptation):DVT 的護理首要目標是預防血栓脫落造成肺栓塞。因此,應避免任何可能增加血栓移動風險的活動,同時採取措施減緩血栓擴大與緩解症狀。

Appropriate nursing interventions for a client with suspected deep vein thrombosis include elevating the affected extremity to promote venous return and applying warm, moist compresses to reduce pain and inflammation. Administering ordered anticoagulants is essential to prevent further clot formation. Ambulation and massage are contraindicated in the acute phase as they may dislodge the thrombus and cause a pulmonary embolism.

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