— 照護管理 · MEDIUM · SATA —
護理師為高跌倒風險病人規劃護理計畫，應包含哪些措施？（選所有適合的）
Which of the following interventions are appropriate for a nurse to include in a plan of care for a client at high risk for falls? (Select all that apply.)
- AKeep the call light within easy reach of the client✓ 正解將求助鈴置於病人容易觸及之處
- BPlace the client in a room far from the nursing station將病人安置於遠離護理站的病房
- CEncourage the client to wear non-slip footwear✓ 正解鼓勵病人穿著防滑鞋
- DKeep the hospital bed in the lowest position✓ 正解將病床維持在最低位置
- EApply soft physical restraints to keep the client in bed使用軟性物理約束將病人固定在床上
— Explanation · 中文詳解 —
跌倒預防是醫療機構內病人安全（Patient Safety）的核心指標。護理計畫必須採取多維度措施，從環境改善（低床位、呼叫鈴）、個人輔具（防滑鞋）到行為監測。選擇措施時應遵循「最小限制性原則」（Least Restrictive Environment），約束並非預防跌倒的首選，因為其可能導致病人更躁動或發生併發症。
Fall prevention requires a multidimensional approach focusing on environmental safety and patient independence. Keeping the bed in the lowest position, providing non-slip footwear, and ensuring the call light is within reach minimize injury risk and promote safe mobility. Restraints are avoided as they are not a first-line strategy and may increase agitation.
✦ 台美臨床差異
美國臨床非常強調「無約束照護」（Restraint-free environment），僅在絕對必要時才使用，且必須嚴格遵守評估與定期釋放的法規。