護理師照護一位有癲癇病史的病人,應採取哪些措施以確保安全?(選所有適合的)
A nurse is caring for a client with a history of seizures. Which interventions should be implemented to ensure safety? (Select all that apply.)
- AKeep the side rails up and padded✓ 正解保持床欄升起並加墊
- BKeep suction equipment at the bedside✓ 正解在床邊備妥抽吸設備
- CKeep a padded tongue blade at the bedside在床邊備妥加長舌壓板
- DLoosen any restrictive clothing around the neck✓ 正解鬆開頸部任何限制性衣物
- EPlace the client on their side during a seizure✓ 正解發作時將個案置於側臥位
癲癇(Seizure)發作時,護理的核心原則是「預防受傷(Safety)」與「維持呼吸道通暢(Patent airway)」。護理師應在發作前預防跌倒,發作中確保環境安全,發作後擺位以預防吸入性肺炎。現代護理實務已嚴格禁止在發作時使用壓舌板或任何物體放入病人口中,因為這極高機率導致牙齒斷裂、軟組織受傷,甚至阻塞呼吸道。
To ensure safety for a client with a history of seizures, the nurse should keep side rails padded to prevent injury during tonic-clonic movements, place the client on their side to promote airway drainage, and loosen restrictive clothing around the neck to aid respiratory effort. Suction equipment should be kept at the bedside to manage post-ictal secretions. However, padded tongue blades should never be placed at the bedside, as inserting objects into the mouth during a seizure can cause dental trauma and airway obstruction.