— 基本照護與舒適 · MEDIUM · SATA —
護理師為跌倒高風險病人制定照護計畫，應包含哪些內容？（選所有適合的）
Which of the following interventions should the nurse include in the plan of care for a client at risk for falls? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解保持病床處於最低位置
- BPlace the call light within reach✓ 正解將呼叫鈴放置在伸手可及之處
- CEncourage the client to wear non-slip socks✓ 正解鼓勵病人穿著防滑襪
- DRestrain the client to the bed將病人約束於病床上
- EEnsure adequate lighting in the room✓ 正解確保室內有充足的照明
— Explanation · 中文詳解 —
跌倒預防的核心在於環境安全與病人教育。低床位、呼叫鈴在手邊、止滑襪、充足照明均可降低跌倒機率。約束病人是最後手段且需醫師開立醫囑，不可作為預防跌倒的例行性措施，濫用約束可能導致病人躁動反而增加跌倒風險。
Fall prevention strategies include keeping the bed in the lowest position, ensuring the call light is within reach, encouraging the use of non-slip socks, and maintaining adequate room lighting. Physical restraints are not a routine intervention for fall prevention due to associated risks and the requirement for a physician's order.
✦ 台美臨床差異
美規對於約束（Restraint）規範嚴格，傾向使用離床警報器；台灣對於失智病人運用約束仍較為普遍，但評估標準正逐漸與國際接軌。