# 選取所有當加護病房個案轉為舒適照護時適當的行動。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375162&lang=zh-tw  
> language: zh-TW  
> subject: Basic Care and Comfort  
> category: BCC

## 題目

選取所有當加護病房個案轉為舒適照護時適當的行動。

1記錄修訂後的目標，並停止不協助舒適的檢驗或治療。
2開立預先需要的PRN類鴉片藥物，並在需要時開立抗焦慮藥物；依症狀調整劑量。
3根據同意的照護目標，停用ICD電擊並重新考慮升壓劑。
4支持家屬在場，符合個案的意願，並提供靈性關懷服務。
5繼續常規的實驗室抽血並增加升壓劑，以使每一項生理數值正常化。
6持續約束、警報器及限制訪客，即使它們未改善舒適或安全。
7提供口腔護理、翻身擺位，並處理呼吸困難、疼痛、焦慮及吵雜的分泌物。

## 解析

舒適照護為主的照護，是將每項處置與緩解痛苦及記錄的照護目標相互配合。停止造成負擔的非舒適檢驗與治療；開立並依症狀調整類鴉片藥物以緩解疼痛或呼吸困難，並於需要時給予抗焦慮藥物；停用ICD電擊治療；並透過授權的照護目標流程，重新考慮升壓劑或其他延長生命的支持措施。支持個案期望的家屬與靈性陪伴，並持續進行口腔護理、翻身擺位、分泌物處理及其他護理舒適措施。常規的實驗室抽血、增加升壓劑、限制訪客以及無益的監測，與僅以舒適為目標的計畫並不一致。

## 深入解析

Compassionate拔管:預先給藥、家屬準備、停用呼吸器。記錄詳細舒適醫囑含PRN劑量。

## 臨床情境

多重器官衰竭、無恢復可能。家屬同意舒適照護。

## 重要概念

- **舒適照護** — 當治癒非目標時聚焦於緩解痛苦。
- **ICD停用** — 停用除顫器電擊功能,必要時保留心搏緩起搏。
- **臨終呼嚕音** — 分泌物造成呼吸聲 — 以體位與抗蕈毒鹼藥處理。

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