— 生理適應 · MEDIUM · MCQ —
護理師照護一位疑似深層靜脈栓塞（DVT）的病人。下列哪項護理措施是禁忌的？
A nurse is caring for a client with suspected deep vein thrombosis (DVT). Which nursing action is contraindicated?
- AElevating the affected extremity抬高患肢
- BMonitoring for signs of pulmonary embolism監測肺栓塞跡象
- CApplying warm compresses to the area在患處敷熱敷包
- DMassaging the affected leg to improve circulation✓ 正解按摩患肢以改善循環
— Explanation · 中文詳解 —
深層靜脈栓塞病人絕對禁止按摩患肢（Massage the affected leg）。按摩可能會導致原本附著於血管壁的血栓脫落，形成栓子進入血液循環，進而引發致命的肺栓塞（Pulmonary Embolism）。其他選項如抬高患肢與溫敷有助於緩解腫脹與疼痛，是合適的護理處置。
Massaging the affected leg is strictly contraindicated in clients with suspected deep vein thrombosis because it may dislodge the thrombus and cause a pulmonary embolism. Appropriate interventions include elevating the limb and monitoring for signs of embolization.
✦ 台美臨床差異
台美皆嚴格執行此項禁忌。美國護理師在預防 DVT 的 protocol 執行上非常嚴謹（如早期的預防性抗凝劑與彈性襪）。