一位深部靜脈血栓 (DVT) 病人正接受持續肝素輸注。護理師發現其血小板計數在 48 小時內從 250,000/mm³ 降至 90,000/mm³。護理師應優先採取哪項行動？
A client is being treated for deep vein thrombosis (DVT) with a continuous heparin infusion. The nurse notes the client's platelet count has dropped from 250,000/mm³ to 90,000/mm³ within 48 hours. Which action should the nurse take first?
- AAssess the client for signs of bleeding評估個案是否有出血跡象
- BDocument the finding and continue monitoring記錄此發現並繼續監測
- CSlow the heparin infusion rate減慢肝素輸注速率
- DNotify the healthcare provider✓ 正解通知醫療提供者
血小板數值大幅下降（通常指下降超過 50%）是肝素引發的血小板低下症 (Heparin-Induced Thrombocytopenia, HIT) 的典型表現。這是一種嚴重的免疫反應，雖然血小板減少，但病人反而面臨極高的「血栓」風險（白血栓）。處理 HIT 的首要步驟是立即停用所有形式的肝素並通知醫師。雖然評估出血（A）很重要，但通知醫師（D）以獲得停藥醫囑並更換其他抗凝劑（如 Argatroban）是挽救生命的最關鍵行動。減慢流速（C）是無效且危險的，因為免疫反應與劑量無關。護理師必須能識別這種「數值矛盾」的危險（血小板低卻要防血栓），這是減少風險潛力的高階臨床判斷。及時介入可防止肢體壞疽或中風。
A significant drop in platelet count (typically a decrease of more than 50%) is the classic presentation of Heparin-Induced Thrombocytopenia (HIT). This is a serious immune reaction; despite the low platelet count, the client paradoxically faces an extremely high 'thrombosis' risk (white clots). The first step in managing HIT is to immediately discontinue all forms of heparin and notify the provider. While assessing for bleeding (A) is important, notifying the provider (D) to obtain orders to stop the drug and switch to an alternative anticoagulant (e.g., Argatroban) is the most critical life-saving action. Slowing the infusion (C) is ineffective and dangerous because the immune reaction is unrelated to dose. The nurse must recognize this 'paradoxical numerical' danger (low platelets but the patient must be protected from thrombosis), which is a higher-order clinical judgment to reduce risk. Timely intervention can prevent limb gangrene or stroke.
美國 NCLEX 邏輯中，遇到 HIT 這種緊急且需更改治療方案的情況，「通知醫師」常被列為首選（因為護理師不能私自停藥）；台灣臨床上，護理師通常會先關掉點滴，再同步電話回報醫師狀況。