彈力襪與充氣加壓裝置

1、彈力襪與充氣加壓裝置(Elastic Stockings and Sequential Compression Devices) 彈力襪與充氣加壓裝置 (Elastic Stockings and Sequential Compression Devices)1. 患者有糖尿病，處于昏迷狀態(tài)，且每2個小時需要翻身一次。入院時，護士發(fā)現(xiàn)患者的腿部發(fā)紺并且發(fā)涼，兩只小腿上各有一處硬幣大小的壓瘡。護士意識到該名患者：A. 可能患有DVT并經(jīng)過霍曼斯征評估B. 與彈力襪相比，能從SCD中受益更多C. 可能不適合使用彈力襪或SCDD. 有發(fā)生靜脈淤血的風(fēng)險，需要使用彈力襪正確答案 C. 可能不適合使用彈

2、力襪或SCD題解該名患者不適合使用彈力襪或SCD。使用彈力襪或SCD的禁忌情況包括皮炎或開放性損傷（如壓瘡），近期植皮，表現(xiàn)為肢體發(fā)紺、發(fā)涼的下肢血液循環(huán)降低，和 /或影響到下肢的壞疽?；袈拐鞑豢煽?。盡管研究顯示大多數(shù)患者從SCD中的收益比彈力襪多，但該名患者兩種都不適用。因為腿部的壓瘡，這名有靜脈淤血風(fēng)險的患者不適合使用彈力襪。2. 一名患者將彈力襪卷下“涼快一下”，因為彈力襪讓腿變得“熱且出汗“。護士應(yīng)該指導(dǎo)患者：A. 彈力襪在使用前可以浸泡在水中來使腿部感到?jīng)鏊珺. 如果不舒適，患者應(yīng)該直接將襪子脫下C. 如果卷下襪子能讓患者覺得更舒適，那就可以這樣做D. 彈力襪在每次輪班中可以脫下一

3、小段時間正確答案 D. 彈力襪在每次輪班中可以脫下一小段時間題解彈力襪可以脫下一小段時間以進行評估和/或清潔措施，但需要盡早更換。將襪子部分卷下會產(chǎn)生壓迫的效果并影響靜脈回流。長時間脫下彈力襪會使患者處于栓塞的危險中。不建議浸泡彈力襪The patient is diabetic and comatose and needs to be turned every 2 hours. On admission, the nurse notices that the patients legs are cyanotic and cool, with two dime-size ulcers on e

4、ach calf. The nurse recognizes that the patient:A. May have a DVT and needs to be evaluated using Homans procedureB. Benefits more from SCDs than elastic stockingsC. May not be a candidate for elastic stockings or SCDD. Is at risk for venous stasis and needs elastic stockingsC. May not be a candidat

5、e for elastic stockings or SCDCorrect AnswerRationaleThe patient is not a candidate for elastic stockings or SCD. Conditions that might contraindicate use of elastic stockings or SCDs include dermatitis or an open skin lesion (such as an ulcer), recent skin graft, decreased circulation in lower extr

6、emities as evidenced by cyanotic, cool extremities, and/or gangrenous conditions affecting the lower limb(s). Homans sign is not reliable. While research suggests that the most patients would benefit more from the use of SCDs over elastic stockings, in this case the patient is not a candidate for ei

7、ther. The patient at risk for venous stasis is not a candidate for elastic stockings because of the leg ulcer.A patient rolls down the elastic stockings to cool down because the stockings make the legs hot and sweaty. The nurse should instruct the patient that:A. Elastic stockings can be soaked in w

8、ater before application to keep the legs coolB.If uncomfortable, the patient should just take the stockings offC.It is okay to keep the stockings rolled if the patient is more comfortable D. Elastic stockings can be removed for a short period once a shiftCorrect AnswerRationaleThe elastic stockings

9、can be removed for a short period to perform an assessment and/or hygiene measures but need to be replaced as soon as possible. Rolling socks partially down has a constricting effect and can impede venous return. Removing elastic hose for long periods places the patient at risk for embolism. Soaking

10、 elastic stockings is not recommended.3. 充氣加壓裝置可以：A. 用于患者夜間睡覺時B. 一天24小時/一周7天使用C. 單獨使用或與彈力襪合并使用D. 在白天使用，因為夜間其噪音會影響患者睡眠正確答案 A. 用于患者夜間睡覺時題解根據(jù)醫(yī)生的偏好，充氣加壓裝置可以單獨使用或者與彈力襪合并使用。SCD在白天和夜間均可使用，但需要在每次輪班時至少脫下一次。4. 一名患者在髖關(guān)節(jié)置換術(shù)后臥床休息，護士評估患者的血液循環(huán)和凝血功能檢查是為了檢查患者是否存在：A. 出血傾向增加B. 感染征象C. 血小板減少D. Virchow三要素正確答案 D. Virchow三

11、要素題解有3個因素（通常稱為Virchow三要素）促進了DVT的發(fā)展：血液高凝狀態(tài)，靜脈壁損傷和血流淤滯。感染征象最好通過查看白細胞計數(shù)和分類以及生命體征和臨床表現(xiàn)來評估。出血傾向增加可以通過凝血功能檢查發(fā)現(xiàn)，但是不能了解臥床休息患者因為靜止和血液淤滯導(dǎo)致DVT的風(fēng)險。血小板減少提示血小板計數(shù)偏低和出血傾向。5. 一名患者因“疑似DVT”入院。護士評估患者時發(fā)現(xiàn)其腿部溫?zé)?，伴有輕度水腫。護士不應(yīng)當(dāng)進行霍曼斯征測試，因為：A. 它不可靠B. 它很痛苦C. 伴有輕度水腫，可以排除靜脈血栓形成D. 按壓腿部可能導(dǎo)致腦卒中正確答案 A. 它不可靠題解不到20%的DVT患者會表現(xiàn)出霍曼斯征陽Sequen

12、tial compression devices are used:A. At night when the patient is sleepingB. 24 hours a day/7 days a weekC. Alone or with elastic stockingsD.In the daytime, because the noise keeps patients awake at nightA. At night when the patient is sleepingCorrect AnswerRationaleSequential compression devices ca

13、n be used alone or in conjunction with elastic stockings, depending on the practitioners preference. SCDs are worn both day and night but need to be removed at least once per shift.When a patient is on bed rest following hip replacement, the nurse should assess the patients circulation and coagulati

14、on studies in an attempt to check the patient for:A. Increased bleeding tendencyB. Signs of infectionC. ThrombocytopeniaD. Virchows triad D. Virchows triadCorrect AnswerThree elements (commonly referred to as Virchows triad) contribute to the development of DVT: hypercoagulability of the blood, veno

15、us wall damage, and stasis of blood flow. Signs of infection are best assessed by looking at the white blood cell count and differential as well as vital signs and the clinical picture. Increased bleeding tendencies may be recognized in the coagulation studies, but the risk for a patient on bed rest

16、 is DVT caused by inactivity and blood stasis. Thrombocytopenia is an indicator of a low platelet count and possible risk for bleeding.A patient is admitted with a diagnosis of “possible DVT.” The nurse assesses the patient and finds that the leg is slightly warm, with minimal edema. The nurse shoul

17、d not pursue testing for Homans sign because:A. It is not reliableB. It is extremely painfulC. With minimal edema, venous thrombosis is excludedD. Manipulation of the leg could lead to stroke A. It is not reliableCorrect AnswerRationale性?；袈拐麝栃员憩F(xiàn)為足背屈時出現(xiàn)小腿不適?；袈拐鳒y試會造成疼痛并不是不進行這項測試的原因。水腫出現(xiàn)與否并不能排除DVT的診斷

18、。按壓腿部會導(dǎo)致血栓運行到肺部，而不是腦部6. 護士為有發(fā)生DVT風(fēng)險的患者腿部使用彈力襪的目的是：A. 減少通過腿部的血流B. 增加靜脈擴張并防止靜脈撕裂C. 對損傷的靜脈加壓使血液凝固D. 促進靜脈回流并防止靜脈擴張正確答案 D. 促進靜脈回流并防止靜脈擴張題解彈力襪有助于降低與DVT形成相關(guān)的2個因素。能夠通過維持淺表靜脈壓力來防止靜脈淤滯，促進靜脈回流，從而減少下肢血栓形成的風(fēng)險；還能防止靜脈的被動擴張，從而減少發(fā)生內(nèi)皮撕裂的風(fēng)險。彈力襪不會減少通過腿部的血流，不會增加靜脈擴張或?qū)p傷的靜脈加壓使血液凝固。使用彈力襪的目的是為了防止血栓形成，而不是促使其形成。7. 在為一名老年患者預(yù)定

19、彈力襪時，護士應(yīng)該記得：A. 老年人可能出現(xiàn)肌肉消瘦，因此需要對他們進行仔細測量B. 老年人同時需要彈力襪和SCDC. 老年人因為脂肪儲存量減少，通常靜脈回流會增加D. 老年患者的彈力襪幾乎不可能不出現(xiàn)褶皺正確答案 A. 老年人可能出現(xiàn)肌肉消瘦，因此需要對他們進行仔細測量題解老年人因為衰老的過程會出現(xiàn)肌肉消瘦；因此，仔細測量這類患者以得到合適的尺寸尤為重要。正常的生理衰老會掩蓋靜脈功能不全的癥狀和體征。將彈力襪上的所有皺褶撫平十分關(guān)鍵，因為皺褶會導(dǎo)致壓力增加和循Fewer that 20% of patients with a DVT exhibit a positive Homans sig

20、n. A positive Homans sign is indicated by leg discomfort when the foot is dorsiflexed. The fact that the Homans test can be painful is not the reason for not pursuing the test. The presence or absence of edema does not exclude the diagnosis of DVT. Manipulation of the legs can result in clots travel

21、ing to the lungs but not the brain.The nurse should apply elastic stockings to the legs of a patient at risk for DVT for the purpose of:A. Decreasing blood flow through the legsB. Enhancing venous dilation and reducing the risk of venous tearsC. Applying pressure to damaged vessels and causing clott

22、ingD. Promoting venous return and preventing venous dilationD. Promoting venous return and preventing venous dilationElastic stockings help reduce two of the elements related to DVT formation. They promote venous return by maintaining pressure on superficial veins to prevent venous pooling, thereby

23、reducing the risk of clot formation in the lower extremities; and they prevent passive dilation of the veins, thereby decreasing the risk of endothelial tears. Elastic stockings do not decrease blood flow through the legs, increase venous dilation, or apply pressure to damaged vessels resulting in c

24、lotting. The purpose of elastic stockings is to prevent clots not cause them.When ordering elastic stockings for an elderly patient, the nurse should remember that:A. Older adults may experience muscle wasting, so they need careful measurementB. Older adults require SCDs along with elastic stockings

25、C. Older adults usually have enhanced venous return because of loss of fat storesD. It is almost impossible to get wrinkles out of the stockings of older patients A. Older adults may experience muscle wasting, so they need careful measurementCorrect AnswerRationaleOlder adults may experience muscle

26、wasting because of the aging process; therefore, it is essential to measure these patients carefully to ensure proper fit. Normal physiologic aging can mask the signs and symptoms of venous insufficiency. It is essential that all wrinkles be smoothed out of elastic stockings 環(huán)改變。根據(jù)醫(yī)生的喜好，彈力襪可以單獨使用，也可

27、以與SCD聯(lián)合使用。8. 下列哪一項是使用彈力襪和SCD時準(zhǔn)確測量患者氣囊套尺寸最重要的理由？A. 準(zhǔn)確測量才能達到最佳的襪子壓力B. 身高和體重會影響小腿的周長C. 合適的尺寸有助于使用D. 合適的尺寸確保血液循環(huán)評估時腳趾沒有被覆蓋正確答案 A. 準(zhǔn)確測量才能達到最佳的襪子壓力題解將患者的測量結(jié)果與生產(chǎn)廠家的尺寸表對照。最佳的彈力襪壓力是腳踝處20到30mmHg，大腿的中上段降低到8mmHg。這種壓力變化能在安全和實用的基礎(chǔ)上，最大限度增加靜脈回流速率。在使用彈力襪和SCD時，不需要測量身高和體重。合適的尺寸能夠保證裝置的輕松使用，但這不是主要的治療目的。如果腳趾沒有被覆蓋，他們會被壓迫，影響到血液循環(huán)。because wrinkles lead to increased pressure and alter circulation. Elastic hose may be used alone or with SCDs, according to the practitioners preference.Which of the following is the most important reason to accurately determine sleeve size when measuring a patient for