一位病人被診斷為深層靜脈栓塞(DVT)。哪些護理措施是適當的?(選所有適合的)
A client is diagnosed with deep vein thrombosis (DVT). Which nursing interventions are appropriate? (Select all that apply.)
- AMaintain strict bed rest as ordered✓ 正解依醫囑維持嚴格卧床休息
- BApply warm compresses to the area在患部應用熱敷
- CMassage the affected limb to reduce swelling按摩患肢以減輕腫脹
- DElevate the affected limb✓ 正解抬高患肢
- EAdminister anticoagulant medication✓ 正解給予抗凝血藥物
深層靜脈栓塞(DVT)的核心護理目標是預防血栓脫落導致肺栓塞(Pulmonary Embolism, PE)。治療重點在於穩定血栓、促進靜脈回流及藥物抗凝。嚴格臥床是為了減少下肢肌肉運動造成的血栓脫落風險;抬高患肢利用重力促進靜脈血回流,減少水腫;抗凝血劑(如肝素 Heparin 或華法林 Warfarin)則是防止血栓擴大或新生。禁止按摩或熱敷患部是因為這些動作可能導致栓子鬆脫。臨床護理需優先確保血栓穩定,避免任何可能干擾血栓附著的機械性刺激。
The primary goal in managing deep vein thrombosis is to prevent pulmonary embolism by stabilizing the clot and promoting venous return. Appropriate interventions include maintaining bed rest to minimize movement that could dislodge the thrombus, elevating the affected limb to reduce edema, and administering anticoagulants to prevent further clot formation. Massage and heat application are contraindicated as they may cause the clot to break loose.