護理師協助一位右側肢體無力的病人使用單點手杖行走。護理師的哪一項行動是適當的？
A nurse is assisting a client who has right-sided weakness to ambulate with a single-point cane. Which action by the nurse is appropriate?
- AInstruct the client to hold the cane in the left hand while walking指導病人行走時用左手握住手杖正確答案
- BInstruct the client to hold the cane in the right hand while walking指導病人行走時用右手握住手杖
- CStand on the client's left side while the client is walking病人行走時，護理師站在病人的左側
- DInstruct the client to move the left leg forward before moving the cane指導病人先把左腿向前移動，再移動手杖
- A指導病人行走時用左手握住手杖
正確答案是 A。單點手杖應握在健側，也就是與無力的腿相對的那一側；本例病人右側無力，因此手杖握在左手。這樣在右腿承重時，左手的手杖可提供支撐點並模擬正常行走時對側手腳交替擺動的模式，讓重心維持在支撐面內。B：把手杖握在患側會使重心偏向無力的一側，反而增加跌倒風險。C：護理師應站在病人的患側（右側）稍後方，必要時使用步行腰帶（gait belt），才能在病人向弱側傾倒時及時扶持；站在左側保護不到傾倒的方向。D：正確順序是手杖先向前，接著移動患側（右）腿，最後健側（左）腿跟上，也可採手杖與患側腿同時前進的兩點步態；健側腿先於手杖移動，會讓病人在沒有支撐的情況下把重量壓在無力的腿上。手杖高度以手把約在腕部皺褶或大轉子高度、握杖時手肘微屈 15 至 30 度為準。來源：Potter & Perry, Fundamentals of Nursing（Assistive devices for ambulation）；Mayo Clinic, Tips for choosing and using canes。
- A · 正確答案指導病人行走時用左手握住手杖
正確。手杖握在健側（左手）與無力的右腿相對，可在右腿承重時提供支撐並維持重心，這就是 COAL 原則。
- B指導病人行走時用右手握住手杖
錯誤。手杖握在患側會使重心偏向無力的右側，減少支撐效果並增加跌倒風險。
- C病人行走時，護理師站在病人的左側
錯誤。護理師應站在病人的患側（右側）稍後方，才能在病人向弱側傾倒時及時支撐；站在左側保護不到傾倒的方向。
- D指導病人先把左腿向前移動，再移動手杖
錯誤。順序應為手杖先動、再移動患側右腿，最後健側左腿跟上；健側腿先動會讓體重壓在沒有支撐的右腿上。
美國 NCLEX 強調 COAL 原則（Cane Opposite Affected Leg）與明確的步行順序，護理師常與物理治療師共同訓練並使用步行腰帶；台灣醫院的拐杖衛教同樣使用四點、三點、兩點步態等名稱，手杖也由健側手握持，原則與美國相同。 台灣出處：臺大醫院護理部〈漫談拐杖之使用〉（2017）；高雄榮民總醫院骨科部〈常用輔助行走器具之介紹及使用方法〉（2026）
English explanation
Option A is correct. A single-point cane is held on the stronger side, opposite the weak leg, so a client with right-sided weakness holds the cane in the left hand. When weight is borne on the right leg, the cane in the opposite hand provides a point of support and reproduces the normal reciprocal arm and leg pattern of walking, keeping the center of gravity within the base of support. Option B is incorrect because holding the cane on the weak side shifts the center of gravity toward that side and increases the risk of falling. Option C is incorrect because the nurse stands slightly behind the client on the affected right side, using a gait belt when needed, so support can be given if the client leans toward the weaker side; standing on the stronger side leaves that direction unprotected. Option D is incorrect because the sequence is to advance the cane first, then the affected right leg, and finally the unaffected left leg, although a two-point pattern moving the cane and the right leg together is also acceptable. Moving the stronger leg first places weight on the weak leg without support. The cane handle should reach the wrist crease or greater trochanter, with the elbow flexed 15 to 30 degrees. Source: Potter & Perry, Fundamentals of Nursing (assistive devices for ambulation); Mayo Clinic, Tips for choosing and using canes.
最近修訂：2026-10-05