護理師準備給予一位心房顫動病人 Warfarin。病人最近一次的 INR 數值為 5.2。護理師接下來應採取哪項行動？
A nurse is preparing to administer warfarin to a client with atrial fibrillation. The client's most recent INR is 5.2. Which action should the nurse take next?
- AAdminister the dose as prescribed按醫囑給藥
- BAdminister vitamin K intramuscularly immediately立即肌肉注射維生素K
- CHold the dose and notify the healthcare provider✓ 正解暫停給藥並通知醫療提供者
- DAdminister half of the prescribed dose給予處方劑量的一半
Warfarin 的治療目標範圍（Therapeutic range）通常在 INR 2.0-3.0 之間。當 INR 達到 5.2 時，病人面臨極高的出血風險。在這種情況下，護理師的首要責任是「降低風險」，即暫停（Hold）給藥並通報醫師以獲取進一步指示。護理師絕對不能擅自調整劑量（D）。雖然維生素 K 是解毒劑，但除非有嚴重的活動性出血或醫囑指示，否則通常不會立即肌肉注射（B），且高 INR 的處置通常先從停藥開始。通報後，醫師可能會開立維生素 K 或僅要求停藥直到 INR 回降。安全性永遠優先於執行藥物醫囑。
The therapeutic range for warfarin is typically an INR of 2.0 to 3.0. When the INR reaches 5.2, the patient is at extremely high risk of bleeding. In this situation, the nurse's primary responsibility is to 'reduce risk,' which means holding the dose and notifying the physician for further instructions. The nurse must not adjust the dose unilaterally (D). Although vitamin K is the antidote, it is usually not given by IM injection immediately (B) unless there is severe active bleeding or a physician order; management of a high INR typically begins with holding the medication. After notification, the physician may order vitamin K or simply have the medication held until the INR decreases. Safety always takes priority over carrying out medication orders.
在美國，INR 的監測常有抗凝血門診（Anticoagulation clinic）專門管理，護理師對治療區間的掌握度極高。台灣醫院中，Warfarin 劑量調整高度依賴醫師，但護理師在發藥前核對最後一次 INR 數值是防止醫療疏失的國際共同標準。