護理師對病人進行預防跌倒衛教,應包含哪些內容?(選所有適合的)
A nurse is teaching a client about fall prevention. Which items should be included in the plan? (Select all that apply.)
- AKeep the call bell within reach✓ 正解將呼叫鈴放在觸手可及之處
- BWear non-skid footwear✓ 正解穿著防滑鞋
- CEncourage the client to get up quickly鼓勵病人快速起身
- DKeep the room well-lit at night✓ 正解夜間保持房間照明充足
- ERemove loose rugs from the floor✓ 正解移除地板上的鬆動地毯
核心概念:病室環境安全與跌倒預防(Fall Prevention)。 為何正確答案對: A. 確保呼叫鈴(call bell)在病人可及範圍內。病人需要協助時能立即取得呼叫鈴,可減少其自行下床移動的風險,降低跌倒機率。 B. 穿著防滑鞋(non-skid footwear)。防滑鞋底能增加腳與地面的摩擦力,尤其是在濕滑或光滑的地面上,有效預防滑倒。 D. 夜間保持房間照明(keep the room well-lit at night)。充足的照明有助於病人看清楚環境,辨識移動路徑上的障礙物,尤其是在夜間需要起床時。 E. 移除地上的鬆散地毯或電線(remove loose rugs from the floor)。這些物品容易絆倒病人,是常見的跌倒誘因,移除或固定它們能提高環境安全性。 為何其他選項錯: C. 鼓勵病人「快速」起身(Encourage the client to get up quickly)是錯誤的。快速起身可能導致姿勢性低血壓(orthostatic hypotension),引起頭暈、視力模糊,增加跌倒風險。應教導病人緩慢、分階段起身(例如:先坐起,腳垂下數秒,再站起)。 臨床思路/安全優先:跌倒是住院病人常見的意外傷害,可能導致嚴重後果。護理師的責任是評估病人跌倒風險,並採取環境改造和病人教育措施。將病人安全置於首位,預防跌倒是重要的照護目標。
Fall prevention strategies include keeping the call bell within reach to reduce the need for unsupervised ambulation, wearing non-skid footwear for better traction, and ensuring the room is well-lit at night to improve visibility. Loose rugs should be removed to eliminate tripping hazards. Clients should be encouraged to rise slowly to prevent orthostatic hypotension, rather than getting up quickly.