一名病人的右腿被診斷為深部靜脈栓塞 (DVT)。護理師應採取哪項行動以減少肺栓塞風險？
A client is diagnosed with deep vein thrombosis (DVT) in the right leg. Which action should the nurse take to minimize the risk of pulmonary embolism?
- AMassage the affected leg daily每天按摩患肢
- BEncourage bed rest and avoid sudden movements of the leg✓ 正解鼓勵臥床休息並避免腿部突然移動
- CApply sequential compression devices (SCDs) to both legs雙腿都套上間歇性充氣加壓裝置 (SCDs)
- DPlace a heating pad on the right calf在右小腿放置熱敷墊
深部靜脈栓塞（Deep Vein Thrombosis, DVT）是指深層靜脈中形成血栓，最常發生在下肢。DVT 最嚴重的併發症是肺栓塞（Pulmonary Embolism, PE），當血栓脫落，隨血流進入肺動脈，可能導致急性呼吸循環衰竭，危及生命。因此，護理師的首要任務是採取措施防止血栓脫落並轉移。 對於已確診 DVT 的病人，「鼓勵臥床休息並避免腿部突然移動」是減少肺栓塞風險的關鍵措施。臥床休息可以限制患肢活動，減少肌肉收縮對血栓的擠壓，從而降低血栓脫落的機會。突然的移動或劇烈活動會增加靜脈壓力，使血栓更容易脫落。在急性期，此措施對於穩定血栓、防止其移動至肺部至關重要。
Deep vein thrombosis (DVT) refers to the formation of a blood clot in a deep vein, most commonly in the lower extremities. The most serious complication of DVT is pulmonary embolism (PE) — when the thrombus dislodges and travels with the bloodstream to the pulmonary artery, it can cause acute cardiopulmonary collapse and is life-threatening. The nurse's top priority is therefore to take measures that prevent clot dislodgement and migration. For a patient with confirmed DVT, 'encouraging bed rest and avoiding sudden leg movements' is the key measure to reduce pulmonary embolism risk. Bed rest limits movement of the affected limb, reduces muscular compression of the thrombus, and decreases the chance of dislodgement. Sudden movement or vigorous activity raises venous pressure and makes the clot more likely to dislodge. In the acute phase, this measure is critical for stabilizing the clot and preventing migration to the lungs.
美國最新觀點認為若已開始抗凝血治療可早期活動；但傳統教學仍強調急性期限制活動。