— 降低風險 · MEDIUM · SATA —
護理師正在照護一位有深層靜脈栓塞風險的病人。下列哪些護理措施是適當的？（選所有適合的）
A nurse is caring for a client who is at risk for deep vein thrombosis (DVT). Which of the following nursing actions are appropriate? (Select all that apply.)
- AApply sequential compression devices (SCDs)✓ 正解應用循序加壓裝置（SCDs）
- BEncourage early and frequent ambulation✓ 正解鼓勵早期且頻繁的下床活動
- CMassage the calves daily to improve circulation每日按摩小腿以促進循環
- DAdminister prescribed anticoagulants as scheduled✓ 正解按時給予處方抗凝血劑
- EInstruct the client to avoid crossing their legs✓ 正解指示病人避免翹腳
— Explanation · 中文詳解 —
預防 DVT 的核心在於促進血液回流與預防凝血。使用 SCDs 促進下肢血液循環、鼓勵儘早下床活動、規律給予抗凝血劑以及衛教病人避免盤腿或交叉雙腳以防壓迫血管，皆能有效降低血栓風險。切記：禁止按摩患肢，以免導致已形成的血栓剝落造成肺栓塞。
Preventing deep vein thrombosis involves promoting venous return through sequential compression devices, early ambulation, and prescribed anticoagulants. Patients should be instructed to avoid crossing their legs to prevent venous compression. Massaging the calves is contraindicated as it may dislodge a thrombus and cause a pulmonary embolism.
✦ 台美臨床差異
美國護理師常主導 SCDs 的評估與穿戴，台灣臨床則常由照服員協助，護理師需確認其正確性。