— 降低風險 · MEDIUM · MCQ —
護理師照護一位懷疑有深層靜脈栓塞（DVT）的病人，應採取何項行動？
A nurse is caring for a client with a suspected DVT. Which action should the nurse take?
- AMassage the affected limb to promote circulation按摩患肢以促進循環
- BApply hot compresses to the area在該區域應用熱敷
- CEncourage the client to walk to improve blood flow鼓勵病人行走以改善血流
- DMaintain bed rest as ordered✓ 正解依醫囑維持臥床休息
— Explanation · 中文詳解 —
懷疑 DVT 時，最重要是防止栓子脫落造成肺栓塞。絕對禁止按摩患肢（會導致栓子移動），並應建議臥床休息（Bed rest）。按摩與熱敷都會導致栓塞處周邊血管擴張，增加栓子脫落風險。下床活動應在診斷確認且開始抗凝血治療後才考慮。
To prevent pulmonary embolism, the nurse must maintain bed rest to avoid dislodging the thrombus. Massage, heat application, and ambulation are contraindicated as they increase blood flow and the risk of clot migration.
✦ 台美臨床差異
美台對 DVT 的照護指引一致，特別是禁止按摩這項原則在各國護理教育中都列為絕對禁忌。